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Copyright ©2022 by the American Dental Association. All rights reserved. Except
as permitted under the Copyright Act of 1976, no part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in any form or by any
means, electronic, photocopying, recording, or otherwise, without the prior written
permission of ADA, 211 East Chicago Avenue, Chicago, Illinois, 60611.
ISBN: 978-1-68447-167-6
ADA Product No.: P69222
Legal Disclaimer:
This book is sold “as is” and without warranty of any kind, either express or
implied. We make no representations or warranties of any kind about the
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and expressly disclaim all warranties, including all implied warranties
(including any warranty as to merchantability and fitness for a particular
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Neither the publisher nor the author are responsible fo r any damage or loss that
results directly or indirectly from your use of this book. In making these materials
available, the ADA does not, nor does it intend to, provide either legal or
professional advice. Nothing here represents ADA’s legal or professional advice as
to any particular situation you may be facing. To get appropriate legal or
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For more information, including updates, about ADA Catalog publications, visit
ADAcatalog.org.
American Dental Association

211 East Chicago Avenue
Chicago, Illinois 60611-2616
ADA.org
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Acknowledgements
The American Dental Association would like to thank the following
principal contributors:
Shannon E. Mills, DDS, FAGD, ABGD, FICD, FACD, Lead Author
Elizabeth A. Shapiro, DDS, JD, Chief of Governance and Strategy
Management
Diane Metrick, DDS, Senior Manager, Emerging Issues & Council
Activities
Ruth Lipman, PhD, Senior Director, Scientific Information,
Evidence Synthesis & Translation Research
Anita M. Mark, Senior Scientific Content Specialist, Scientific
Information, Evidence Synthesis & Translation Research
Pamela Woolf, Senior Manager, Product Development
Caitlin Wilson, Manager, Product Development
Along with contributors to previous editions: Pamela Porembski,
DDS, John Malone, and Alison Bramhall.
The Council on Dental Practice Mission

Statement
The mission of the Council on Dental Practice is to recommend
policies and provide resources to empower our members to continue
development of the dental practice, and to enhance their personal
and professional lives for the betterment of the dental team and the
patients they serve.
This publication of the American Dental Association is offered as
information only and not as financial, accounting, legal or other
professional advice. Readers need to consult with their personal
advisors for such advice.
Table of Contents
Introduction
COVID-19 Pandemic and Federal Guidelines
Building a Culture of Safety Requires Teamwork and Leadership
Overview of Content
Chapter 1: Fundatmentals of Infection Prevention and
Control
Chapter 2: Disinfection and Sterilization
Chapter 3: Dental Water Quality
Chapter 4: Infection Prevention and Control during Clinical
Procedures
Chapter 5: Special Considerations and Pandemic
Preparedness
Objectives
How to Use This Book
Who Should Use It
How to Begin
To Use This Guide
Continuing Education Credit
Infection Prevention and Control Self-Assessment Checklist
Chapter 1: Fundamentals of Infection
Prevention and Control
Learning Objectives
The Infectious Disease Process: The Chain of Infection
Causative Agent (Pathogen)
Modes of Transmission
Susceptible Host
Occupational Exposure to Bloodborne Pathogens
Preventing Occupational Exposures to Bloodborne Pathogens
Preventing Transmission of Respiratory Pathogens
Transmission-based Precautions
Transmission of COVID-19
Respiratory Hygiene and Cough Etiquette
Precautions and Considerations during Public Health
Emergencies
Source Control and Screening Measures for Respiratory
Symptoms
COVID-19 Testing and Lab Testing in Dental Facilities
Droplet and Airborne Precautions during Public Health
Emergencies
Occupational Health and Safety Education: Making It All Work
for the Dental Team
The Role of the Infection Prevention and Control
Coordinator
Immunizations and Tuberculosis Testing
Comprehensive Written Infection Prevention, Occupational
Health, and Patient Safety Plan
Patient Medical History and Standard Precautions
Employee Health
Needle and Sharps Safety
Employee Medical Conditions, Work-related Illnesses, and
Work Restrictions
Hand Hygiene and Care
Routine Handwashing and Antisepsis
Fingernails and Artificial Nails
Personal Protective Equipment (PPE)
Respiratory Protection: Masks and Fit-tested Particulate
Respirators
Protective Eyewear and Face Shields
Protective Clothing
Gloves
Handwashing and Glove Use for Oral Surgical Procedures
Contact Dermatitis and Latex Allergy
Precautions for Patients with Latex Allergy
Goal-setting Worksheet
Chapter 2: Disinfection and Sterilization

Learning Objectives
Cleaning, Decontamination, Disinfection, and Sterilization
Disinfection Levels
When to Clean, Disinfect, or Sterilize Patient Care Items
Sterilization Methods
Other Methods of Sterilization
Sorting and Preparing Items for Sterilization
Reprocessing Reusable Instruments and Devices
Sterility Assurance
Storage of Sterilized Items and Clean Dental Supplies
Disinfection of Environmental Surfaces
Clinical Contact Surfaces
Housekeeping Surfaces
Dental Laboratory Infection Prevention and Control
Fogging and UV Disinfection
Blood Spills and Disinfection
Nonregulated and Regulated Medical Waste
Handling of Biopsy Specimens
Discharging Blood or Other Body Fluids into Sanitary
Sewers or Septic Tanks
Chapter 3: Dental Water Quality

Learning Objectives
Growth of Bacteria in Dental Waterlines
Managing Dental Unit Water Quality
Sterile Irrigating Solutions for Oral Surgery
Other Indications for the Use of Sterile Irrigating Solutions
Monitoring Dental Water Quality
Municipal Water Systems, Facility Plumbing, and Drinking Water
Advisories
Chapter 4: Infection Prevention and Control

During Clinical Procedures
Learning Objectives
Infection Prevention and Control during the Pretreatment Period
Personal Protective Equipment
PPE Wear under Standard Precautions
Chairside Infection Prevention and Control
Infection Prevention and Control during the Post-treatment
Period
Infection Prevention for Imaging, Scanning, and Sensing
Procedures
Extraoral Radiographic Equipment
Procedures for Handling Film and Phosphor Plates
Digital Radiographic, Photographic, Scanning, and Sensor
Technologies
Keyboards and Other Data Entry Equipment
Summary of Infection Prevention and Control during Patient
Care:
A Four-stage Process
Stage 1: Pretreatment
Stage 2: Chairside
Stage 3: Post-treatment
Stage 4: Radiographic, Photographic, Scanning, and Sensor
Procedures
Chapter 5: Special Considerations and

Pandemic Preparedness
Learning Objectives
Dental Handpieces and Other Devices Attached to Air and
Waterlines
Dental Handpieces and Other Devices Not Connected to Air or
Waterlines
Saliva Ejectors
Aseptic Technique for Parenteral Medications
Single-use or Disposable Devices
Preprocedural Mouthrinses
Handling of Extracted Teeth
Storage and Disposal
Teeth Used in Educational Settings
Laser/Electrosurgery Plumes or Surgical Smoke
Management of Patients with History of Symptoms of TB and
other Highly Infectious Respiratory Diseases
Managing Patients with TB and Preventing Transmission
Management of Patients with Suspected CJD or Other Prion
Diseases
Pandemic and Emergency Preparedness
Chapter Review Questions

Chapter 1 Review Questions
Appendices
A. Glossary
B. List of Acronyms
References
This book includes access to the ADA Practical Guide to Effective

Infection Prevention and Control, Fifth Edition e-book, as well as the
online resources listed below. See the inside front cover for your
redemption code and instructions for accessing your e-book.
Online Resources:
• Infection Prevention and Control Self-Assessment Checklist
• Goal-setting Worksheet Chapter 1: Fundamentals of Infection
Control
• Goal-setting Worksheet Chapter 2: Disinfection and Sterilization
• Goal-setting Worksheet Chapter 3: Dental Water Quality
• Goal-setting Worksheet Chapter 4: Infection Prevention and
Control during Clinical Procedures
• Goal-setting Worksheet Chapter 5: Special Considerations and
Pandemic Preparedness
Introduction
The threat of infectious disease transmission has long
been a primary concern for all healthcare professions,
including dentistry. It comes as a shock, however, to
many younger dental professionals that until the middle
1980s, most dentists practiced what we knew as “wet-
fingered dentistry” and did not routinely wear gloves,
masks, safety eyewear, or other items we now accept as
indispensable personal protective equipment (PPE).1–3
Operative and dental hygiene instruments were often
wiped with alcohol sponges or soaked in low-level
disinfectants between patients, and in many practices,
only surgical instruments were routinely autoclaved.2
Following the development of reliable tests to identify
hepatitis B virus (HBV) antigens and anti-HBV antibodies
in blood, epidemiological studies of dental healthcare
professionals (DHCP) revealed alarmingly high rates of
HBV exposure and chronic infection (carrier status) when
compared to the general population.4, 5 The highest rates
were observed among surgeons and dentists—especially
oral surgeons. Between 1970 and 1987, several case
reports described HBV transmissions from chronically
infected dentists and oral surgeons associated with
invasive clinical procedures.6, 7 Professional organizations
including the American Dental Association (ADA) and the
US Centers for Disease Control and Prevention (CDC)
responded by developing and publishing policy and
procedure guidelines to protect DHCP and patients from
the risk of infection.8 The first ADA dental infection
control guidelines were published in 1978,1 followed by
the CDC Recommended Infection-Control Practices for
Dentistry published in 19869 with updates in 1993,10
2003,11 and 2016.12
Wet-fingered dentistry, however, was not easily
abandoned, nor were recommended infection prevention
strategies quickly adopted even as the acquired
immunodeficiency syndrome (AIDS) pandemic caused by
the human immunodeficiency virus (HIV) surged across
the globe.13 Many practices adopted extraordinary
isolation protocols to treat patients known to be infected
with HIV, while others simply refused to treat them at all.
In 1998, a Supreme Court ruling in a case brought by a
patient who had been refused care by her dentist
extended protections to all Americans living with HIV,
symptomatic or not, as a protected disability under the
Americans with Disabilities Act.14
In 1987, Congress directed the Department of Labor Occupational

Safety and Health Administration (OSHA) to work with the CDC to
create rules that would protect healthcare workers, from exposure to
HBV, HIV, and other bloodborne pathogens. The OSHA Bloodborne
Pathogens Standard (CFR 1910.1030), published in 1991, required
employers to protect workers from direct contact with blood or other
potentially infectious materials while performing their jobs.15–18
Foundational in the Standard was the scientifically sound infection
control practice of “universal precautions” (UP), which assumes all
patients to be infected with a bloodborne pathogen. UP was
originally recommended by the CDC for handling of body fluids
known to transmit HIV, because patients who are infectious often
show no signs or symptoms.19 UP was later modified by CDC to
become Standard Precautions (SP), which, along with required HBV
immunization of DHCP and routine childhood vaccination, has proven
to be highly effective in decreasing the risk of disease transmission
in healthcare settings.20
The era of “wet-fingered” dentistry was hastened to its end when
the CDC reported in 1991 that a Florida dentist had transmitted HIV
to several of his patients—all of whom ultimately succumbed to the
disease.21, 22 As concerns about being infected with HIV in the
dental office spread across the country, the profession responded by
implementing recommended infection prevention practices and
procedures to restore the public’s confidence.23
COVID-19 Pandemic and Federal

Guidelines
Preventing exposure to bloodborne pathogens through universal or
standard precautions and HBV vaccination of DHCP remained the
primary focus and a dramatic success story for dentistry for nearly
three decades. Then, in 2020, the world was rocked by the COVID-
19 pandemic, caused not by a bloodborne virus, but by SARS-CoV-2,
a highly pathogenic respiratory virus easily spread by droplets and
aerosols. COVID-19 was being spread not just in clinical settings, but
through everyday social contact.24, 25 Early in the pandemic, many
dental practices were shut down or limited to providing emergency
care by local authorities to help slow community transmission and, in
some cases, to conserve scarce PPE.
The profession appears to have successfully navigated many of the
challenges of COVID-19, just as it did with HIV and HBV in 1991 and
1992.26, 27 CDC, OSHA, and professional organizations including the
ADA responded with new infection prevention measures to make
dentistry safe for patients and DHCP and help reduce community
transmission. The pandemic should serve as a reminder that there
remains the daily risk of exposure not just to bloodborne pathogens
and airborne pathogens like SARS-CoV-2, but to herpes simplex virus
types 1 and 2,28 cytomegalovirus (CMV),29 influenza,30, 31
measles,32–34 and other viruses and bacteria that colonize or infect
the upper respiratory tract,35 conjunctiva, and skin, as well as
environmental organisms such as Legionella36 and nontuberculous
Mycobacteria (NTM),37, 38 which may be present in water used for
dental treatment.39-43
In 2016, the CDC published the CDC Summary of Infection
Prevention Practices in Dental Settings: Basic Expectations for Safe
Care, based on the 2003 CDC Guidelines for Infection Control in
Dental Health-Care Settings, which remains the recognized national
standard of care. This currently effective publication summarizes the
key elements of the 2003 guideline in a more user-friendly format
and provides new tools and checklists to help the dental team with
successful implementation.12
In response to the COVID-19 pandemic, CDC developed interim
recommendations to deal with this extraordinary public health
emergency.44 These recommendations build on the sound foundation
of SP to develop effective measures against respiratory pathogens
such as SARS-CoV-2. Just as UP, first proposed by CDC for HIV, also
prevent exposure to HBV and HCV, COVID-19 policies and
procedures can also lower risk for spread of other respiratory
infectious diseases, whether they are emerging threats or ancient
maladies like measles, recently resurgent due to vaccine hesitancy
on the part of parents and caregivers.45, 46 Interventions aimed
against SARS-CoV-2 transmission may have substantially reduced
influenza incidence and impact in the 2020–2021 Northern
Hemisphere season.47
This guide synthesizes the most current science-based
recommendations for infection prevention and control in dental
settings from the CDC and Federal agency rules and regulations
(e.g., OSHA, the US Food and Drug Administration [FDA], and the
US Environmental Protection Agency [EPA]). It also includes
standards and technical reports from American National Standards
Institute (ANSI) accredited standards development organizations
including the ADA Standards Committees for Dental Products and
Informatics (SCDP and SCDI), the Association for Advancement of
Medical Instrumentation (AAMI) and recommendations from the
American Dental Association and other professional organizations
such as the Organization for Safety, Asepsis and Prevention (OSAP),
Association of periOperative Registered Nurses (AORN), and the
World Health Organization (WHO).
Building a Culture of Safety

Requires Teamwork and Leadership
Building a culture of safety essential to a successful infection
prevention program requires buy-in at every level of the practice,
organization, institution, or agency, whether a small private practice,
a multi-specialty dental service organization, a Federally Qualified
Health Center, a hospital or medical center dental service, or dental
school. Whether a solo practitioner, a CEO, or a dean, finding the
right individual(s) to lead and manage infection prevention and
safety programs and ensuring that they have the training, resources,
and right level of delegated authority will pay big dividends.48, 49
A culture of safety means that infection prevention and
occupational safety are second nature to dental team members and
are baked into every aspect of clinical operations rather than simply
checklists and policies sitting in a dust-covered notebook on a
forgotten bookshelf.
CDC strongly recommends that facilities assign at least one person in
every dental practice as the infection prevention and control
(IPC) coordinator to implement sound policies and procedures,
monitor program effectiveness, and ensure staff compliance.11, 12
ADA fully supports this recommendation and encourages persons
assigned this role to make use of this guide and other resources
from CDC and other organizations when establishing policies. We
hope this guide will be an indispensable resource for training
members of the dental team, to assure compliance with policies and
correct performance of procedures built on a culture of safety.
A culture of safety means that infection prevention and

occupational safety are second nature to dental team
members and are baked into every aspect of clinical
operations rather than simply checklists and policies
sitting in a dust-covered notebook on a forgotten
bookshelf.
Overview of Content
This book provides a convenient, self-paced learning experience for
all members of the dental healthcare team.
Chapter Fundamentals of Infection Prevention

and Control describes infectious disease
1 processes and provides information about
essential practices required to control and
prevent infections in the dental setting. Key
practices discussed include immunization,
hand hygiene and care, use of personal
protective equipment, and the assigning and
training of an infection prevention and control
(IPC) coordinator. This unit also discusses
post-exposure evaluation and follow-up, work
practice and engineering controls,
transmission-based precautions for
respiratory pathogens, and special
procedures for oral surgery.
Disinfection and Sterilization provides

detailed information on instrument
reprocessing methods, which include their
cleaning, disinfection, sterilization, process
Chapter monitoring, and storage; the types and uses
2 of liquid chemical agents for surface
disinfection; safe disposal of nonregulated
and regulated waste; evaluation of dental
unit water quality; and disinfection of dental
prostheses.
Dental Water Quality provides guidance

for ensuring that water used for surgical and
nonsurgical clinical procedures, handwashing,
Chapter and other applications meets or exceeds
3 current recommendations from CDC, ADA,
EPA, and local health authorities for
microbiological quality and is free from
hazardous chemicals.
Chapter Infection Prevention and Control during

Clinical Procedures provides an overview
4 of infection prevention and control practices
to be used during the provision of clinical
care. As an aid to learning and implementing
these practices, the clinical period is divided
into three phases—pretreatment, clinical
care, and post-treatment—and discusses
measures to prevent transmission of disease
by direct contact, bloodborne, respiratory,
and waterborne routes appropriate for each
phase.
Special Considerations and Pandemic

Preparedness provides detailed information
about the handling of various clinical devices,
Chapter extracted teeth, and treatment of patients
5 with tuberculosis and prion diseases, as well
as how to prepare for public health
emergencies including future pandemic
disease outbreaks and natural disasters.
The guide also contains:

• A self-assessment checklist of current infection
prevention and control practices
• Goal-setting worksheets
• Review questions
• Appendices containing glossary and list of
acronyms
• A list of resources for further research and study
• E-book access and digital copies of all checklists
and worksheets
The self-assessment checklist provides a brief evaluation of the
status of infection prevention and control efforts in the office or
clinic. The goal-setting worksheets assist in setting realistic goals
and developing action plans for implementing an effective infection
prevention and control program.
The list of resources contains references to useful and informative
publications on infection prevention and related topics. Finally,
review questions reinforce key concepts, ideas, and practices. For
those who want to receive continuing education credit for
completing this guide, a CE exam is available on ADACEonline.org.
This book’s content is developed from evidence-based
recommendations of public health groups, regulatory agencies, and
professional organizations; it includes the voluntary consensus of
standards developers. It is not an exhaustive guide to complying
with state, territorial, tribal, or local laws and regulations,
organizational, agency, or institutional policy, or accreditations
standards. Knowledge of the scientific and clinical bases of a law can
certainly help the dentist comply, but dentists who want information
on legal requirements are referred to other resources such as The
ADA Practical Guide to OSHA Compliance: Regulatory Compliance
Manual or other OSHA information resources which can be found at
catalog.ADA.org/.
Objectives
Upon completion of this guide, the user should understand:
• The risks and modes of occupational transmission of infectious
agents in the dental setting, including bloodborne pathogens
such as hepatitis B virus (HBV), hepatitis C virus (HCV), and
human immunodeficiency virus (HIV); organisms transmissible
by direct contact, such as herpes simplex virus (HSV) and
methicillin resistant Staphylococcus aureus (MRSA); diseases
transmissible by airborne routes through droplets and aerosols,
such as COVID-19, varicella (chickenpox), pertussis, measles,
mumps, influenza, and tuberculosis (TB); and organisms that
can be transmitted in water used for dental treatment,
including Legionella species and aquatic nontuberculous
Mycobacteria (NTM).
• The kinds of personal protective equipment (PPE) that should

be used routinely during dental treatment to prevent
bloodborne, contact, droplet or aerosol, and waterborne
exposure to potentially infectious agents.
• The importance of immunization against infection.
• The importance of infection prevention measures to contain

respiratory droplets and aerosols to prevent the spread of
respiratory pathogens when examining and caring for patients
and among dental healthcare professionals (DHCP).
• Strategies such as respiratory hygiene and cough etiquette,

control of droplets and aerosols, and the use of PPE to limit the
spread of infectious agents.
• The limitations of the medical history in identifying individuals

who are infected but may not exhibit signs or symptoms of
disease.
• Standard Precautions (SP) and Universal Precautions (UP) for

prevention of bloodborne exposures.
• Policies for the detection and referral of patients who might

have suspected or active respiratory infection, including SARS-
CoV-2 and TB.
• Infection prevention practices necessary before, during, and

after dental treatment procedures to make the clinical
environment of care safe for patients and DHCP.
• The elements of instrument and materials management,

including unit-dosing, single-use devices, multi-use device
reprocessing, sterilization, sterility assurance, and storage.
• The criteria for determining which items are reusable and

which are single-use disposable and must be safely discarded
in the appropriate waste stream.
• Spaulding’s criteria for disinfection and sterilization of reusable

devices and clinical surfaces and know the appropriate level of
disinfection or sterilization for each category.
• How to select and implement appropriate cleaning,

decontamination, disinfection, sterilization, and storage
methods for different types of reusable dental instruments and
devices.
• Appropriate procedures for safe storage, labeling, and handling

of disinfectants and other chemicals in the dental setting in
conformance with the OSHA Hazard Communication Standard
(CFR 1910.1200).
• The principles and practice of sterility assurance, including the

use of process indicators, biological monitoring, sterile
packaging, and instrument storage.
• What constitutes a bloodborne pathogens exposure incident

and the actions to be taken for post-exposure management.
• How to develop and implement policies and practices to reduce

the risk of occupational exposures to bloodborne, respiratory,
and other pathogens, including hazard risk assessment and
documentation.
• Recommended practices for donning and removing PPE and

know requirements for laundering of reusable garments or
disposal of single-use items.
• Medical conditions and work-related illnesses that may require

work restrictions.
• Policies and procedures to ensure appropriate hand hygiene

and glove use for surgical and nonsurgical procedures.
• The distinction between surgical, nonsurgical, and endodontic

procedures and the different recommendations for site
irrigation for each.
• How to maintain dental unit water quality according to

validated manufacturer instructions from the dental device
and/or waterline treatment manufacturer to control biofilm in
dental waterlines.
• The importance of routine monitoring and documentation of
dental unit water quality to meet or exceed CDC recommended
threshold limits for water used for nonsurgical dental
treatment.
• How to appropriately handle and dispose of regulated and

nonregulated medical waste, including dental amalgam or
other chemical waste regulated by the EPA or local authorities.
• How to safely decontaminate, disinfect, and transport or ship

dental impressions, casts, prostheses, and appliances before
and after sending items to a dental laboratory.
• The importance of establishing standard operating procedures

to safely provide oral health during pandemic emergencies,
water advisories, or natural disasters.
How to Use This Book

Who Should Use It
This book is designed for use by all dental healthcare personnel,
including dentists, hygienists, assistants, dental laboratory
technicians, and administrative staff. This guide can form the basis
of a comprehensive infection prevention and control program for the
dental office or other treatment setting.
How to Begin
Although this guide and its recommendations may be implemented
in many ways, it may be most effective and contribute to building a
culture of safety if members of the dental team proceed through
each chapter together. It may be especially helpful if the learning
experience is led by an experienced infection prevention and control
(IPC) coordinator who is knowledgeable about the policies and
procedures specific to the dental treatment facility.
This approach has several advantages:
• It can help to ensure that all members of the team have
completed the material and understand their roles and
responsibilities.
• The IPC coordinator can use this guide in team meetings to
answer questions and ensure that all employees understand
concepts, policies, and procedures.
• It contributes to setting team goals for implementation that
engage all members of the dental team.
To Use This Guide

1. Appoint a dental team member to serve as IPC coordinator
with the responsibility for ensuring that all team members
complete the training.
2. Begin by completing the Self-assessment Checklist as a way of
reviewing current infection prevention and control practices
and knowledge. Each member of the dental team involved in
patient care should complete the self-assessment. By
comparing team members’ results, you will be able to
determine the consistency of infection prevention and control
efforts and identify differences in perception, opinions, or
practices among individuals.
A digital copy of the checklist is included with the e-book that
accompanies this guide, so you may print and reprint the
assessment as needed. To access your e-book, view the
instructions on the inside front cover of this guide.
3. After completing the self-assessment, proceed through the
chapters in order.
4. Complete the review questions (starting on page 114) for each
chapter before proceeding to the next one. Again, keep the
form included with the program as an original. Print or make
photocopies as needed. A staff meeting is useful for answering
questions and clarifying the material.
5. The Goal-setting Worksheets are provided to assist in the
development of an office infection prevention and control
program. These can also be completed at the staff meeting.
The staff meeting provides an excellent opportunity to begin
developing office policies for infection control. Follow-through
with goals and action plans for establishing an infection
prevention and control program will be improved if the entire
staff is involved in the process.
6. Using input from all members of the dental team, the IPC
coordinator should prepare a manual that describes facility
policies and standard operating procedures (SOPs) for all
essential elements of the IPC and occupational safety and
health (OSH) programs. Each member of the dental team
should sign to acknowledge that they have read and
understand these policies and procedures.
7. The IPC coordinator uses this program to train, evaluate, and
mentor DHCPs in their performance of infection prevention and
control duties, to develop a culture of safety and a safe and
healthy environment of care.
8. As new staff join the dental team, they use this program and
facility policies and SOPs to as part of their formal training.
9. The IPC coordinator, with support from leadership and help
from all members of the dental team, uses this program to
continuously evaluate IPC policies, procedures, and practices to
determine where improvements are needed to conform to
guidelines, comply with regulatory requirements, and ensure a
safe, infection-free environment of care.
10. Practice owners and facility managers ensure that team
members have the necessary PPE and supplies to safely
provide care according to written policies and procedures.
Continuing Education Credit

Individuals who successfully complete this program are eligible
for three hours of continuing education credit. Individuals who
wish to receive continuing education credit must complete the
continuing education exam available on ADACEonline.org.
Infection Prevention and Control

Self-Assessment Checklist
Read each of the following items listed and specify if
they are performed (yes or no) by checking the box
provided.
Which of the following dental treatment facility

policies and programs have been implemented?
• An Infection Prevention and Control (IPC) Coordinator

has been appointed and has received necessary training
to perform these duties.
Yes No
• Written IPC and Occupational Safety and Health (OSH)
policies and standard operating procedures (SOPs) have
been prepared and DHCP have acknowledged that they
have read and understand them.
Yes No
• IPC, OSH, and pandemic/emergency preparedness

plans, policies, and SOPs are reviewed at least annually
and are updated in response to changes to applicable
law, regulation, or organizational polices.
Yes No
• All DHCP receive IPC, OSH, and pandemic/emergency

preparedness education and training at least annually
and as necessary to respond to changes in policy or
procedures.
Yes No
Read each of the following items listed and specify
how often you do each (always, sometimes, never) by
checking the box provided.
Before seating the patient and beginning clinical

treatment, how often do you?
• Use the same infection prevention and control

procedures for all patients based on the risk posed by
the procedure, not solely on perceived risk based on the
patient’s medical history or other personal
characteristics?
Always Sometimes Never
• Protect dental records, charts, radiographs, and digital

devices (e.g., smartphone, laptop, tablet) from
becoming contaminated during patient treatment?
• Keep the operatory free of unnecessary items that may

become contaminated during clinical procedures?
• Remove jewelry before hand hygiene and donning of

gloves and keep fingernails well-trimmed to avoid
puncturing gloves or harboring bacteria?
• Wash hands with soap and water for at least 20 seconds

at the beginning and end of each treatment session and
when they are visibly soiled or have contacted blood,
other potentially infectious material (OPIM), or
contaminated surfaces?
• Wear clean non-sterile gloves when placing barriers,

connecting handpieces, and handling instruments and
materials during operatory set up for nonsurgical
procedures?
• If performing oral surgical procedures, perform a

surgical hand wash and don sterile surgical gloves?
Consider double gloving for procedures that may involve
manipulation of bone or wires or proximity of fingers to
sharps in a constrained space.
• Wear sterile, surgical gloves when setting up for surgical
procedures?
• Use an alcohol-based hand rub (ABHR) before and after

donning gloves between or during dental treatment
except when hands are visibly soiled or have contacted
blood, OPIM, or contaminated surfaces?
• After washing or using an ABHR, don new exam or

procedure gloves for each patient for dental exams,
hygiene visits, and nonsurgical restorative care,
changing them if they become torn or perforated during
treatment?
• Wear respiratory PPE (surgical mask or N95 or

equivalent respirator) appropriate to the anticipated
level of risk from aerosol-generating procedures (AGP)
during anticipated treatment and levels of community
transmission of highly contagious airborne pathogens?
• Wear protective eyewear appropriate to the anticipated

level of risk for generation of droplets, aerosols, and
projectile hazards during anticipated treatment?
• Maintain dental unit waterlines according to

manufacturer’s instructions to meet CDC
recommendations for dental treatment water quality?
• Use an on-site test kit or outside laboratory to ensure

that water meets CDC recommendations and maintain a
log of test results for each dental unit?
• Participate in an annual review of safer sharps (e.g.,

self-sheathing dental anesthetic needles, IV cannulas,
and scalpel blades) as required by the Needlestick Safety
and Prevention Act?50–52
• Whenever possible, use self-sheathing hypodermic

needles and intravenous cannulas?
During and after patient treatment, how often do you?
• Use a one-handed technique or re-capping device to

reduce the risk for injury when recapping of needles is
necessary?
• Use scalpels with self-sheathing blades where possible

and remove non-self-sheathing blades when necessary,
using a hemostat or similar device?
• Carefully discard all used disposable sharps in a
puncture-proof, color-coded, biohazard-labeled sharps
container conveniently located in the operatory?
• Use intraoral high-volume evacuation (HVE) when

performing aerosol-generating procedures (AGP) with
ultrasonic scalers and high-speed handpieces?
• Wear employer-provided personal protective clothing

(e.g., gowns or aprons, shoes, or shoe covers) to cover
personal clothing (e.g., street clothes, personal scrubs,
street shoes) and exposed skin during aerosol- and
droplet-generating procedures. Know that surgical
scrubs worn outside of clinical settings (e.g., to and from
work) are not considered PPE.
• Wear puncture-resistant utility gloves when performing

surface cleaning and disinfection, when handling
reusable sharps, and during instrument reprocessing
activities with contaminated instruments?
• Discard single-use disposable sharps (e.g., needles,

scalpels, endodontic files, burs, metal matrix bands) in
the sharps container after each patient?
• Discard non-sharp, single-use disposable items (e.g.,

cotton rolls, patient napkins, rubber dams, wooden
wedges), either as regulated medical waste, or in
routine trash based on level of contamination with blood
or other potentially infectious material (OPIM)?
• After the patient has left the operatory, clean and

disinfect operatory equipment and other surfaces
contacted during patient treatment with an intermediate
level, hospital disinfectant for the recommended contact
time between patients?
• Barrier protect surfaces contacted during patient

treatment (e.g., light, handles, bracket trays, handpiece
hoses) using single-use disposable covers?
• Follow recommended procedures for donning and

doffing of PPE including masks, face shields, eyewear,
and protective clothing when treatment is complete or
when leaving the operatory?
• Use instrument cassettes with standardized tray setups

for routine or frequently performed procedures?
• Unit-dose and use carbide and diamond burs,

endodontic files, and other rotary instruments once and
then discard as sharps unless FDA-cleared instructions
for cleaning and sterilization are provided by the
manufacturer?
• If bur blocks are used, clean and sterilize them after

removing and replacing items with residual soil or
evidence of wear or corrosion?
• Use high volume evacuation (HVE) and rubber dam or

other isolating device for aerosol- and droplet-generating
restorative procedures for all patients whenever
possible?
• After treatment, transport reusable dental instruments in

a rigid, leak-proof container that is color coded and
marked with a biohazard label to the dedicated
instrument reprocessing area avoiding unnecessary
transit through patient waiting rooms or other
nonclinical areas?
• Thoroughly clean reusable instruments according to

manufacturer instructions to eliminate blood, other
potentially infectious materials (OPIM), and restorative
residues?
• Avoid manual cleaning when possible, and use an

ultrasonic cleaner, automated instrument washer, or
washer disinfector?
• If using an ultrasonic cleaner, thoroughly rinse
instruments with clean water to remove residual
contamination, change cleaning solutions at least daily
or when visibly soiled, and test units for cleaning
efficacy at least monthly?
• After decontamination, ensure that instruments are

thoroughly dry and have been inspected for damage,
corrosion, or visible residual soil before wrapping or
placement in sterilization pouches?
• Remove and replace instruments that are damaged,

corroded, or have visible residual soil?
• Use external and internal chemical process indicators for

each sterilization cycle?
• Use biological monitors for assessing sterilization at least

weekly or according to local regulations and for any load
that includes an implantable device?
• Load and pack trays correctly in the sterilizer to allow

adequate contact with steam?
• Sterilize instruments and devices using sterilization
cycles specified by the manufacturer?
• Monitor gauges to ensure that sterilization parameters

have been met, preferably using sterilizers that provide
a print-out to document the sterilization cycle?
• Use chemical sterilization for recommended contact

times only for critical or semi-critical items (see
Spaulding Criteria in chapter 2) that cannot withstand
heat sterilization? Whenever possible, replace non-heat-
stable items with those that can be heat sterilized.
• Disinfect and document the process used for items

before sending them to the dental laboratory?
• Follow CDC-recommended respiratory hygiene and

cough etiquette procedures?53
• Have completed a vaccination series for hepatitis B with

follow-up antibody testing; or have completed a signed
form declining hepatitis B vaccination as recommended
by CDC and required by the OSHA Bloodborne
Pathogens Standard?16, 54, 55
• Have completed a vaccination series for SARS-CoV-2
(COVID-19) or have completed a signed form declining
COVID-19 vaccination if required as a condition of work
by the dental treatment facility or employer? (See the
ADA white paper Ethics of Vaccination for guidance on
establishing a vaccine policy for your facility.56)
• Are current with other recommended vaccinations or

documentation including for influenza, measles, mumps,
rubella, varicella (chickenpox),57–59 or have completed a
signed form declining these vaccinations or documenting
history of previous infection if required as a condition of
work by the dental treatment facility or employer?
• Screen all patients according to current CDC guidelines

and state, territorial, tribal, or local laws and regulations
intended to prevent transmission of highly contagious
respiratory infections (e.g., COVID-19,60 influenza,30
measles32) prior to providing treatment?
• Consider deferring non-emergency treatment for

persons known or reasonably suspected of having a
significant and potentially infectious respiratory infection
(e.g., influenza,30 COVID-19,60 measles,32
tuberculosis61)?
• At a minimum, wear a surgical mask and protective

eyewear for all patient encounters?11
Chapter 1
Fundamentals of Infection
Learning Objectives
The Infectious Disease Process: The Chain of Infection
Occupational Exposure to Bloodborne Pathogens
Preventing Occupational Exposures to Bloodborne
Pathogens
Preventing Transmission of Respiratory Pathogens
Precautions and Considerations during Public Health
Emergencies
Occupational Health and Safety Education: Making It All
Work for the Dental Team
Patient Medical History and Standard Precautions
Employee Health
Hand Hygiene and Care
Personal Protective Equipment (PPE)
Contact Dermatitis and Latex Allergy
Chapter 1
Fundamentals of Infection
Learning Objectives
Upon completion of this chapter, you should be able to:

• Describe the infectious disease process
• Apply the concept of Standard Precautions for

prevention of bloodborne pathogen exposure
• Apply the concept of transmission-based

precautions for diseases spread by contact,
droplet, or airborne routes of transmission
• Discuss the importance of immunizations to

prevent transmission of infectious diseases in the
clinical setting and the community
• Implement the CDC-recommended protocols for

respiratory hygiene and cough etiquette
• Demonstrate proper handwashing technique

• Select and properly don and remove the personal
protective equipment to be used during clinical
care
• Describe what to do following an exposure

incident
• Apply engineering and work practice controls to

reduce the risk of exposure to blood and other
potentially infectious material
• Implement infection prevention and control

techniques for surgical procedures
Developing and implementing an effective and practical infection

prevention plan for your setting requires that you learn some of the
basics about infectious diseases and the way in which they are
spread in the community and dental environment.
The dental team is more likely to comply with an infection
prevention program if they understand why it is important to the
health and safety of their patients, the community, and themselves.
Clearly written policies, procedures, and guidelines can help ensure
consistency, efficiency, and effective coordination of activities.
This guide provides practical and effective information and tools to
educate dental healthcare professionals (DHCP) about the
prevention of infectious diseases and creation of a healthy and safe
workplace. Having DHCP periodically reassess themselves using the
checklists will encourage continuous quality improvement of facility
infection prevention and occupational health programs.
This chapter begins with a discussion of the infectious disease
process, including the factors resulting in transmission of infection,
mechanisms of transfer, and information about exposure to agents in
the dental health care setting. Following presentation of these
topics, information is provided on basic health and infection
prevention and control practices for the dental team. Among the
topics covered are immunizations, respiratory hygiene and cough
etiquette, source control measures, post-exposure management and
follow-up, medical history and standard and transmission-based
precautions, hand hygiene, personal protective equipment (PPE)
(e.g., gloves, mask, gown, and protective eyewear), and contact
dermatitis and latex allergy.
Before we get into the details, this may be a good time to define
some terms that can be confusing but will help us better understand
how infectious agents cause disease. (A detailed glossary of terms
is available beginning on page 125.)
A pathogen is a microbe capable of causing host damage. The
definition includes traditionally recognized pathogens and
opportunistic pathogens. Host damage can result from either direct
microbial action or the host immune response.62
An agent that can cause disease is described as pathogenic. If an
organism is highly pathogenic, it means it is easily transmitted and
often results in infection but does not necessarily mean the disease
that results is serious or deadly. The common cold, COVID-19, and
Ebola Fever are all caused by highly pathogenic organisms but differ
greatly in their relative capacity to cause serious illness.
Virulence describes the relative capacity of a pathogen to cause
damage to the host. This can cover a wide spectrum of interactions
between the host and pathogen that involve multiple factors
including host resistance and microbial characteristics.62 Some
infectious agents may be pathogenic and are easily transmitted, but
show low virulence (e.g., common cold). Others may be less easily
transmitted but show high virulence (e.g., tuberculosis). Some
organisms, like SARS-CoV-2, are both highly pathogenic and virulent
in susceptible populations.
Another thing to keep in mind is that most of the microorganisms
that colonize a host cause no signs or symptoms and are often
beneficial. What in traditional medical microbiology we used to call
“normal flora,” is now increasingly being understood as a complex
and essential relationship between the human host and the
communities of bacteria, fungi, and viruses that colonize skin and
the respiratory, digestive, and genitourinary tracts. Collectively, these
organisms make up our individual microbiome, which some
suggest may be as important as our genome to our overall health
and well-being. Scientists continue to unravel the role the
microbiome plays in critical functions like protecting us from
pathogens, synthesizing vitamins, and aiding digestion.63
The Infectious Disease Process: The

Chain of Infection
The process by which infectious diseases are transmitted involves at
least four essential components, commonly referred to as the chain
of infection:
• A causative agent (pathogen)
• A human, animal, or environmental reservoir (where the agent
grows or survives before transmission)
• A mode of transmission (e.g., direct or indirect contact,
droplet, aerosol, or vector) including portal of exit from the
reservoir and portal of entry into the host
• A susceptible host (e.g., patient or DHCP)
Figure 1.1. Chain of Infection

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made them work too long. His face brightened ever so little, as though the
sun had found a way to him. But suddenly that wooden look, the only safe
and perfect look, came back to his features. One could have sworn that fear
had never touched him, so expressionless, so still was he!
FASHION
VI
Fashion
I have watched you this ten minutes, while your carriage has been standing
still, and have seen your smiling face change twice, as though you were
about to say; “I am not accustomed to be stopped like this”; but what I have
chiefly noticed is that you have not looked at anything except the persons
sitting opposite and the backs of your flunkeys on the box. Clearly nothing
has distracted you from following your thought: “There is pleasure before
me, I am told!” Yours is the three-hundredth carriage in this row that blocks
the road for half a mile. In the two hundred and ninety-nine that come
before it, and the four hundred that come after, you are sitting too—with
your face before you, and your unseeing eyes.
Resented while you gathered being; brought into the world with the most
distinguished skill; remembered by your mother when the whim came to
her; taught to believe that life consists in caring for your clean, well-
nourished body, and your manner that nothing usual can disturb; taught to
regard Society as the little ring of men and women that you see, and to feel
your only business is to know the next thing that you want and get it given
you—You have never had a chance!
You take commands from no other creature; your heart gives you your
commands, forms your desires, your wishes, your opinions, and passes
them between your lips. From your heart well-up the springs that feed the
river of your conduct; but your heart is a stagnant pool that has never seen
the sun. Each year when April comes, and the earth smells new, you have
an odd aching underneath your corsets. What is it for? You have a husband,
or a lover, or both, or neither, whichever suits you best; you have children,
or could have them if you wished for them; you are fed at stated intervals
with food and wine; you have all you want of country life and country
sports; you have the theatre and the opera, books, music, and religion! From
the top of the plume, torn from a dying bird, or the flowers, made at an
insufficient wage, that decorate your head, to the sole of the shoe that
cramps your foot, you are decked out with solemn care; a year of labour has
been sewn into your garments and forged into your rings—you are a
breathing triumph!
You live in the centre of the centre of the world; if you wish you can
have access to everything that has been thought since the world of thought
began; if you wish you can see everything that has ever been produced, for
you can travel where you like; you are within reach of Nature’s grandest
forms and the most perfect works of art. You can hear the last word that is
said on everything, if you wish. When you do wish, the latest tastes are
servants of your palate, the latest scents attend your nose—You have never
had a chance!
For, sitting there in your seven hundred carriages, you are blind—in
heart, and soul, and voice, and walk; the blindest creature in the world.
Never for one minute of your life have you thought, or done, or spoken for
yourself. You have been prevented; and so wonderful is this plot to keep
you blind that you have not a notion it exists. To yourself your sight seems
good, such is your pleasant thought. Since you cannot even see this hedge
around you, how can there be anything the other side? The ache beneath
your corsets in the spring is all you are ever to know of what there is
beyond. And no one is to blame for this—you least of all.
It was settled, long before the well-fed dullard’s kiss from which you
sprang. Forces have worked, in dim, inexorable progress, from the remotest
time till they have bred you, little blind creature, to be the masterpiece of
their creation. With the wondrous subtlety of Fate’s selection, they have
paired and paired all that most narrowly approaches to the mean, all that by
nature shirks the risks of living, all that by essence clings to custom, till
they have secured a state of things which has assured your coming, in your
perfection of nonentity. They have planted you apart in your expensive
mould, and still they are at work—these gardeners never idle—pruning and
tying night and day to prevent your running wild. The Forces are proud of
you—their waxen, scentless flower!
The sun beats down, and still your carriage does not move; and this
delay is getting on your nerves. You cannot imagine what is blocking-up
your way! Do you ever imagine anything? If all those goodly coverings that
contain you could be taken off, what should we find within the last and
inmost shell—a little soul that has lost its power of speculation. A soul that
was born in you a bird and has become a creeping thing; wings gone, eyes
gone, groping, and clawing with its tentacles what is given it.
You stand up, speaking to your coachman! And you are charming,
standing there, to us who, like your footman, cannot see the label “Blind.”
The cut of your gown is perfect, the dressing of your hair the latest, the
trimming of your hat is later still; your trick of speech the very thing; you
droop your eyelids to the life; you have not too much powder; it is a lesson
in grace to see you hold your parasol. The doll of Nature! So, since you
were born; so, until you die! And, with his turned, clean-shaven face, your
footman seems to say: “Madam, how you have come to be it is not my
province to inquire. You are! I am myself dependent on you!” You are the
heroine of the farce, but no one smiles at you, for you are tragic, the most
tragic figure in the world. No fault of yours that ears and eyes and heart and
voice are atrophied so that you have no longer spirit of your own!
Fashion brought you forth, and she has seen to it that you are the image
of your mother, knowing that if she made you by a hair’s-breadth different,
you would see what she is like and judge her. You are Fashion, Fashion
herself, blind, fear-full Fashion! You do what you do because others do it;
think what you think because others think it; feel what you feel because
others feel it. You are the Figure without eyes.
And no one can reach you, no one can alter you, poor little bundle of
others’ thoughts; for there is nothing left to reach.
In your seven hundred carriages, you pass; and the road is bright with
you. Above that road, below it, and on either hand, are the million things
and beings that you cannot see; all that is organic in the world, all that is
living and creating, all that is striving to be free. You pass, glittering, on
your round, the sightless captive of your own triumph; and the eyes of the
hollow-chested work-girls on the pavement fix on you a thousand eager
looks, for you are strange to them. Many of their hearts are sore with envy;
they do not know that you are as dead as snow around a crater; they cannot
tell you for the nothing that you are—Fashion! The Figure without eyes!
SPORT
VII
Sport
Often in the ride of some Scotch wood I used to stand, clutching my gun,
with eyes moving from right to left, from left to right. Every nerve and fibre
of my body would receive and answer to the slightest movements, the
smallest noises, the faintest scents. The acrid sweetness of the spruce-trees
in the mist, the bite of innumerable midges, the feel of the deep, wet, mossy
heather underfoot, the brown-grey twilight of the wood, the stillness—these
were poignant as they never will be again. And slowly, back of that
stillness, the noises of the beaters would begin. Gentle and regular, at first—
like the ending of a symphony rather than its birth—they would swell, then
drop and fade away completely. In that unexpected silence a squirrel
scurried out along a branch, sat a moment looking, and scurried back; or,
with its soft, blunt flight, an owl would fly across.
Then, with a shrill, far “Mar-r-rk!” the beaters’ chorus would rise again,
drowned for an instant by the crack of the keepers’ guns; louder and louder
it came, rhythmically, inexorably nearer. In the ride little shivers of wind
shook the drops of warm mist off the needles of the spruce, and a half-
veiled sun faintly warmed and coloured everything. Stealing through
heather and fern would come a rabbit, confiding in the space before him
and the ride where he was wont to sun himself. At a shot he flung his mortal
somersault, or disappeared into a burrow, reached too soon. To see him lie
there dead in the brown-grey twilight of the trees would give one a strange
pleasure—a feeling such as some casual love affair will give a man, the
pleasure of a primitive virility expressed—but to watch him disappear into
the earth would irritate, for he had got his death, and, dead within the earth,
he would not do one any sort of credit. Nor was it nice to think that he was
dying slowly, so one forbore to think.
Sometimes we did not shoot at such small stuff, but waited for the
roedeer. These dun familiars of the wood were very shy, clinging to the
deepest thickets, treading with gentle steps, invisible as spirits, and ever
trying to break back. Now and then, leaping forward with hindquarters
higher than its shoulders, one of them would face the line of beaters, and
then would arise the strangest noises above the customary sounds and
tappings—cries of fierce resentment that such fine “game” should thus
escape the guns. When the creature crossed the line these cries swelled into
a long, continuous, excited shriek; and, as the yells died out in muttering, I
used to feel a hollow sense of disappointment.
When the beat was over they would collect the birds and beasts which
had fulfilled their destiny, and place them all together. Half hidden by the
bracken or deep heather the little bodies lay abandoned to the ground with
the wonderful strange limpness of dead things. We stood looking at them in
the misty air, acrid with the fragrance of the spruce-trees; and each of us
would feel a vague strange thirst, a longing to be again standing in the rides
with the cries of the beaters in our ears, and creatures coming closer, closer
to our guns.
Often in the police-courts I have sat, while they drove another kind of
“game.”
It would be quiet in there but for the whisperings and shufflings peculiar
to all courts of law. Through the high-placed windows a grey light fell
impartially, and in it everything looked hard and shabby. The air smelled of
old clothes, and now and then, when the women were brought in, of the
corpse of some sweet scent.
Through a door on the left-hand side they would drive these women, one
by one, often five or six, even a dozen, in one morning. Some of them
would come shuffling forward to the dock with their heads down; others
walked boldly; some looked as if they must faint; some were hard and
stoical as stone. They would be dressed in black, quite neatly; or in cheap,
rumpled finery; or in skimped, mud-stained garments. Their faces were of
every type—dark and short, with high cheek-bones; blowsy from drink;
long, worn, and raddled; one here and there like a wild fruit; and many
bestially insensible, devoid of any sort of beauty.
They stood, as in southern countries, one may see many mules or asses,
harnessed to too-heavy loads of wood or stone, stand, utterly unmoving,
with a mute submissive viciousness. Now and then a girl would turn half
round towards the public, her lips smiling defiantly, but her eyes never
resting for a moment, as though knowing well enough there was no place
where they could rest. The next to her would seem smitten with a sort of
deathlike shame, but there were not many of this kind, for they were those
whom the beaters had driven in for the first time. Sometimes they refused to
speak. As a rule they gave their answers in hard voices, their sullen eyes
lowered; then, having received the meed of justice, went shuffling or
flaunting out.
They were used to being driven, it was their common lot; a little piece of
sport growing more frequent with each year that intervened between their
present and that moment when some sportsman first caught sight of them
and started out to bring them down. From most of them that day was now
distant by many thousand miles of pavement, so far off that it was hard
work to remember it. What sport they had afforded since! Yet not one of all
their faces seemed to show that they saw the fun that lay in their being
driven in like this. They were perhaps still grateful, some of them, at the
bottom of their hearts for that first moment when they came shyly towards
the hunter, who stood holding his breath for fear they should not come;
unable from their natures to believe that it was not their business to attract
and afford them sport. But suddenly in a pair of greenish eyes and full lips
sharpened at their corners, behind the fading paint and powder on a face,
one could see the huntress—the soul as of a stealing cat, waiting to flesh its
claws in what it could, driven by some deep, insatiable instinct. This one
too had known sport; she had loved to spring and bring down the prey just
as we who brought her here had loved to hunt her. Nature had put sport into
her heart and into ours; and behind that bold or cringing face there seemed
to lurk this question: “I only did what you do—what nearly every man of
you has done a little, in your time. I only wanted a bit of sport, like you:
that’s human nature, isn’t it? Why do you bring me here, when you don’t
bring yourselves! Why do you allow me in certain bounds to give you sport,
and trap me outside those bounds like vermin? When I was beautiful—and I
was beautiful—it was you who begged of me! I gave until my looks were
gone. Now that my looks are gone, I have to beg you to come to me, or I
must starve; and when I beg, you bring me here. That’s funny isn’t it, d——
d funny! I’d laugh, if laughter earned my living; but I can’t afford to laugh,
my fellow-sportsmen—the more there are of you the better for me until I’m
done for!”
Silently we men would watch—as one may watch rats let out of a cage
to be pounced upon by a terrier—their frightened, restless eyes cowed by
coming death; their short, frantic rush, soon ended; their tossed, limp
bodies! On some of our faces was a jeering curiosity, as though we were
saying: “Ah! we thought that you would come to this.” A few faces—not
used to such a show—were darkened with a kind of pity. The most were
fixed and hard and dull, as of men looking at hurtful things they own and
cannot do without. But in all our unmoving eyes could be seen that
tightening of fibre, that tenseness, which is the mark of sport. The beaters
had well done their work; the game was driven to the gun!
It was but the finish of the hunt, the hunt that we had started, one or
other of us, some fine day, the sun shining and the blood hot, wishing no
harm to any one, but just a little sport.
MONEY
VIII
Money
Every night between the hours of two and four he would wake, and lie
sleepless, and all his monetary ghosts would come and visit him. If, for
instance, he had just bought a house and paid for it, any doubt he had
conceived at any time about its antecedents or its future would suddenly
appear, squatting on the foot-rail of his bed, staring in his face. There it
would grow, until it seemed to fill the room; and terror would grip his heart.
The words: “I shall lose my money,” would leap to his lips; but in the dark
it seemed ridiculous to speak them. Presently beside that doubt more doubts
would squat. Doubts about his other houses, about his shares; misgivings as
to Water Boards; terrors over Yankee Rails. They took, fantastically, the
shape of owls, clinging in a line and swaying, while from their wide black
gaps of mouth would come the silent chorus: “Money, money, you’ll lose
all your money!” His heart would start thumping and fluttering; he would
turn his old white head, bury his whisker in the pillow, shut his eyes, and
con over such investments as he really could not lose. Then, beside his head
half-hidden in the pillow, there would come and perch the spectral bird of
some unlikely liability, such as a lawsuit that might drive him into
bankruptcy; while, on the other side, touching his silver hair, would squat
the yellow fowl of Socialism. Between these two he would lie unmoving,
save for that hammering of his heart, till at last would come a drowsiness,
and he would fall asleep....
At such times it was always of his money and his children’s and
grandchildren’s money that he thought. It was useless to tell himself how
few his own wants were, or that it might be better for his children to have to
make their way. Such thoughts gave him no relief. His fears went deeper
than mere facts; they were religious, as it were, and founded in an
innermost belief that, by money only, Nature could be held at bay.
Of this, from the moment when he first made money, his senses had
informed him, and slowly, surely, gone on doing so, till his very being was
soaked through with the conviction. He might be told on Sundays that
money was not everything, but he knew better. Seated in the left-hand aisle,
he seemed lost in reverence—a grandchild on either hand, his old knees in
quiet trousers, crossed, his white-fringed face a little turned towards the
preacher, one neat-gloved hand reposing on his thigh, the other keeping
warm a tiny hand thrust into it. But his old brain was far away, busy
amongst the Tables of Commandment, telling him how much to spend to
get his five per cent. and money back; his old heart was busy with the little
hand tucked into his. There was nothing in such sermons, therefore, that
could quarrel with his own religion, for he did not hear them; and even had
he heard them, they would not have quarrelled, his own creed of money
being but the natural modern form of a religion that his fathers had
interpreted as the laying-up of treasure in the life to come. He was only able
nowadays to say that he believed in any life to come, so that his
commercialism had been forced to find another outlet, and advance a step,
in accordance with the march of knowledge.
His religious feeling about money did not make him selfish, or niggardly
in any way—it merely urged him to preserve himself—not to take risks that
he could reasonably avoid, either in his mode of life, his work, or in the
propagation of his children. He had not married until he had a position to
offer to the latter, sufficiently secure from changes and chances in this
mortal life, and even then he had not been too precipitate, confining the
number to three boys, and one welcome girl, in accordance with the
increase of his income. In the circles where he moved, his course of action
was so normal that no one had observed the mathematical connection
between increasing income and the production and education of his family.
Still less had any one remarked the deep and silent process by which there
passed from him to them the simple elements of faith.
His children, subtly, and under cover of the manner of a generation
which did not mention money in so many words, had sucked in their
father’s firm religious instinct, his quiet knowledge of the value of the
individual life, his steady and unconscious worship of the means of keeping
it alive. Calmly they had sucked it in, and a thing or two besides. So long as
he was there they knew they could afford to make a little free with what
must come to them by virtue of his creed. When quite small children, they
had listened, rather bored, to his simple statements about money and the
things it bought; presently that instinct—shared by the very young with
dogs and other animals—for having of the best and consorting with their
betters, had helped them to see the real sense of what he said. As time went
on, they found gentility insisting more and more that this instinct should be
concealed; and they began unconsciously to perfect their father’s creed,
draping its formal tenets in the undress of an apparent disregard. For the
dogma, “Not worth the money!” they would use the words, “Not good
enough!” The teaching, “Business first,” they formulated, “Not more
pleasure than your income can afford, your health can stand, or your
reputation can assimilate.” There was money waiting for them, and they did
not feel it necessary to undertake even those “safe” risks which their father
had been obliged to take, to make that money. But they were quite to be
depended on. In the choosing of their friends, their sports, their clubs, and
occupations, a religious feeling guided them. They knew precisely just how
much their income was, and took care neither to spend more nor less. And
so devoutly did they act up to their principles, that, whether in the restaurant
or country house, whether in the saleroom of a curio shop, whether in their
regiments or their offices, they could always feel the presence of the
godhead blessing their discreet and comfortable worship. In one respect,
indeed, they were more religious than their father, who still preserved the
habit of falling on his knees at night, to name with Tibetan regularity a
strange god; they did not speak to him about this habit, but they wished he
would not do it, being fond of their old father, who continued them into the
past. They had gently laughed him out of talking about money, they had
gently laughed at him for thinking of it still; but they loved him, and it
worried them in secret that he should do this thing, which seemed to them
dishonest.
With their wives and husband—in course of time they had all married—
they very often came to see him, bringing their children. To the old man
these little visitors were worth more than all hydropathy; to help in playing
with the toys that he himself had given them, to stroke his grandsons’
yellow heads, and ride them on his knee; to press his silver whiskers to their
ruddy cheeks, pinching their little legs to feel how much there was of them,
and loving them the more, the more there was to love—this made his heart
feel warm. The dearest moments, he knew now, the consolation of his age,
were those he spent reflecting how—of the young things he loved, who
seemed to love him too a little—not one would have secured to him or her
less than twelve or thirteen hundred pounds a year; more, if he could
manage to hold on a little longer. For fifty years at least the flesh and blood
he left behind would be secure. His eye and mind, quick to notice things
like that, had soon perceived the difference of the younger generation’s
standards from his own; his children had perhaps a deeper veneration for
the means of living while they were alive, but certainly less faith in keeping
up their incomes after they were in their graves. And so, unconsciously, his
speculation passed them by, and travelled to his grandchildren, telling itself
that these small creatures who nestled up against him, and sometimes took
him walks, would, when they came to be grown men and women, have his
simpler faith, and save the money that he left them, for their own
grandchildren. Thus, and thus only, would he live, not fifty years, but a
hundred, after he was dead. But he was rendered very anxious by the law,
which refused to let him tie his money up in perpetuity.
Firm in his determination to secure himself against the future, he
opposed this strenuous piety to those temptations which beset the
individual, refusing numberless appeals, often much against his instincts of
compassion; opposing with his vote and all his influence movements to
increase the rates or income-tax for such purposes as the raising of funds to
enable aged people without means to die more slowly. He himself, who laid
up yearly more and more for the greater safety of his family, felt, no doubt
—though cynicism shocked him—that these old persons were only an
encumbrance to their families, and should be urged to dwindle gently out.
In such private cases as he came across, feeling how hard it was, he prayed
for strength to keep his hand out of his pocket, and strength was often given
him. So with many other invitations to depart from virtue. He fixed a
certain sum a year—a hundred pounds—with half-a-crown in the velvet bag
on Sundays—to be offered as libations to all strange gods, so that they
might leave him undisturbed to worship the true god of money. This was
effectual; the strange gods, finding him a man of strong religious principle,
yet no crank—his name appeared in twenty charitable lists, five pounds
apiece—soon let him be, for fear of wasting postage stamps and the under
parts of boots.
After his wife’s death, which came about when he was seventy, he
continued to reside alone in the house that he had lived in since his
marriage, though it was now too large for him. Every autumn he resolved to
make a change next spring; but when spring came, he could not bring
himself to tear his old roots up, and put it off till the spring following, with
the hope, perhaps, that he might then feel more inclined.
All through the years that he was living there alone, he suffered more
and more from those nightly visitations, of monetary doubts. They seemed,
indeed, to grow more concrete and insistent with every thousand pounds he
put between himself and their reality. They became more owl-like, more
numerous, with each fresh investment; they stayed longer at a time. And he
grew thinner, frailer, every year; pouches came beneath his eyes.
When he was eighty, his daughter, with her husband and children, came
to live with him. This seemed to give him a fresh lease of life. He never
missed, if he could help it, a visit to the nursery at five o’clock. There,
surrounded by toy bricks, he would remain an hour or more, building—
banks or houses, ships or churches, sometimes police-stations, sometimes
cemeteries, but generally banks. And when the edifice approached
completion, in the glory of its long white bricks, he waited with a sort of
secret ecstasy to feel a small warm body climb his back, and hear a small
voice say in his ear: “What shall we put in the bank to-day, Granddy?”
The first time this was asked, he had hesitated long before he answered.
During the thirty years that had elapsed since he built banks for his own
children, he had learned that one did not talk of money now, especially
before the young. One used a euphemism for it. The proper euphemism had
been slow to spring into his mind, but it had sprung at last; and they had
placed it in the bank. It was a very little china dog. They placed it in the
entrance hall.
The small voice said: “What is it guarding?”
He had answered: “The bank, my darling.”
The small voice murmured: “But nobody could steal the bank.”
Looking at the little euphemism, he had frowned. It lacked completeness
as a symbol. For a moment he had a wild desire to put a sixpence down, and
end the matter. Two small knees wriggled against his back, arms tightened
round his neck, a chin rubbed itself impatiently against his whisker. He
muttered hastily:
“But they could steal the papers.”
“What papers?”
“The wills, and deeds, and—and cheques.”
“Where are they?”
“In the bank.”
“I don’t see them.”
“They’re in a cupboard.”
“What are they for?”
“For—for grown-up people.”
“Are they to play with?”
“NO!”
“Why is he guarding them?”
“So that—so that everybody can always have enough to eat.”
“Everybody?”
“Everybody.”
“Me, too?”
“Yes, my darling; you, of course.”
Locked in each other’s arms they looked down sidelong at the little
euphemism. The small voice said:
“Now that he’s there, they’re safe, aren’t they?”
“Quite safe.”
He had given up attending to his business, but almost every morning, at
nearly the same hour, he would walk down to his club, not looking very
much at things about the streets, partly because his thoughts were otherwise
engaged, partly because he had found it from the first a deleterious habit,
tending to the overcultivation of the social instincts. Arriving, he would
take the Times and the Financial News, and go to his pet armchair; here he
would stay till lunch-time, reading all that bore in any way on his affairs,
and taking a grave view of every situation. But at lunch a longing to express
himself would come, and he would tell his neighbours tales of his little
grandsons, of the extraordinary things they did, and of the future he was
laying up for them. In the pleasant warmth of mid-day, over his light but
satisfying lunch, surrounded by familiar faces, he would recount these tales
in cheerful tones, and his old grey eyes would twinkle; between him and his
struggle with those nightly apparitions, there were many hours of daylight,
there was his visit to the nursery. But, suddenly, looking up fixedly with
strained eyes, he would put a question such as this: “Do you ever wake up
in the night?” If the answer were affirmative, he would say: “Do you ever
find things worry you then out of—out of all proportion?” And, if they did,
he would clearly be relieved to hear it. On one occasion, when he had
elicited an emphatic statement of the discomfort of such waking hours, he
blurted out: “You don’t ever see a lot of great owls sitting on your bed, I
suppose?” Then, seemingly ashamed of what he had just asked, he rose, and
left his lunch unfinished.
His fellow-members, though nearly all much younger than himself, had
no unkindly feeling for him. He seemed to them, perhaps, to overrate their
interest in his grandsons and the state of his investments; but they knew he
could not help preoccupation with these subjects; and when he left them,
usually at three o’clock, saying almost tremulously: “I must be off; my
grandsons will be looking out for me!” they would exchange looks as
though remarking: “The old chap thinks of nothing but his grandchildren.”
And they would sit down to “bridge,” taking care to play within the means
their fathers had endowed them with.
But the “old chap” would step into a hansom, and his spirit, looking
through his eyes beneath the brim of his tall hat, would travel home before
him. Yet, for all his hurry, he would find the time to stop and buy a toy or
something on the way.
One morning, at the end of a cold March, they found him dead in bed,
propped on his pillows, with his eyes wide open. Doctors, hastily called in,
decided that he had died from failure of heart action, and fixed the hour of
death at anything from two to four; by the appearance of his staring pupils
they judged that something must have frightened him. No one had heard a
noise, no one could find a sign of anything alarming; so no one could
explain why he, who seemed so well preserved, should thus have suddenly
collapsed. To his own family he had never told the fact, that every night he
woke between the hours of two and four, to meet a row of owls squatting on
the foot-rail of his bed—he was, no doubt, ashamed of it. He had revealed
much of his religious feeling, but not the real depth of it; not the way his
deity of money had seized on his imagination; not his nightly struggles with
the terrors of his spirit, nor the hours of anguish spent, when vitality was
low, trying to escape the company of doubts. No one had heard the
fluttering of his heart, which, beginning many years ago, just as a sort of
pleasant habit to occupy his wakeful minutes in the dark, had grown to be
like the beating of a hammer on soft flesh. No one had guessed, he least of
all, the stroke of irony that Nature had prepared to avenge the desecration of
her law of balance. She had watched his worship from afar, and quietly
arranged that by his worship he should be destroyed; careless, indeed, what
god he served, knowing only that he served too much.
They brought the eldest of his little grandsons in. He stood a long time
looking, then asked if he might touch the cheek. Being permitted, he kissed
his little finger-tip and laid it on the old man’s whisker. When he was led
away and the door closed, he asked if “Granddy” were “quite safe”; and
twice again that evening he asked this question.
In the early light next morning, before the house was up, the under-
housemaid saw a white thing on the mat before the old man’s door. She
went, and stooping down, examined it. It was the little china dog.
PROGRESS
IX
Progress
Motor cars were crossing the Downs to Goodwood Races. Slowly they
mounted, sending forth an oily reek, a jerky grinding sound; and a cloud of
dust hung over the white road. Since ten o’clock they had been mounting,
one by one, freighted with the pale conquerors of time and space. None
paused on the top of the green heights, but with a convulsive shaking
leaped, and glided swiftly down; and the tooting of their valves and the
whirring of their wheels spread on either hand along the hills.
But from the clump of beech-trees on the very top nothing of their
progress could be heard, and nothing seen; only a haze of dust trailing
behind them like a hurried ghost.
Amongst the smooth grey beech-stems of that grove were the pallid
forms of sheep, and it was cool and still as in a temple. Outside, the day was
bright, and a hundred yards away in the hot sun the shepherd, a bent old
man in an aged coat, was leaning on his stick. His brown face wrinkled like
a walnut, was fringed round with a stubble of grey beard. He stood very
still, and waited to be spoken to.
“A fine day?”
“Aye, fine enough; a little sun won’t do no harm. ’Twon’t last!”
“How can you tell that?”
“I been upon the Downs for sixty year!”
“You must have seen some changes?”
“Changes in men—an’ sheep!”
“An’ wages, too, I suppose. What were they when you were twenty?”
“Eight shillin’ a week.”
“But living was surely more expensive?”
“So ’twas; the bread was mortial dear, I know, an’ the flour black! An’
piecrust, why, ’twas hard as wood!”
“And what are wages now?”
“There’s not a man about the Downs don’t get his sixteen shillin’; some
get a pound, some more.... There they go! Sha’n’t get ’em out now till tew
o’clock!” His sheep were slipping one by one into the grove of beech-trees
where, in the pale light, no flies tormented them. The shepherd’s little dark-
grey eyes seemed to rebuke his flock because they would not feed the
whole day long.
“It’s cool in there. Some say that sheep is silly. ’Tain’t so very much that
they don’t know.”
“So you think the times have changed?”
“Well! There’s a deal more money in the country.”
“And education?”
“Ah! Ejucation? They spend all day about it. Look at the railways too,
an’ telegraphs! See! That’s bound to make a difference.”
“So, things are better, on the whole?”
He smiled.
“I was married at twenty, on eight shillin’ a week; you won’t find them
doing such a thing as that these days—they want their comforts now.
There’s not the spirit of content about of forty or fifty years agone. All’s for
movin’ away an’ goin’ to the towns; an’ when they get there, from what
I’ve heard, they wish as they was back; but they don’t never come.”
There was no complaining in his voice; rather, a matter-of-fact and
slightly mocking tolerance.
“You’ll see none now that live their lives up on the Downs an’ never
want to change. The more they get the more they want. They smell the
money these millioneers is spendin’—seems to make ’em think they can do
just anythin’ ’s long as they get some of it themselves. Times past, a man
would do his job, an’ never think because his master was rich that he could
cheat him; he gave a value for his wages, to keep well with himself. Now, a
man thinks because he’s poor he ought to ha’ been rich, and goes about
complainin’, doin’ just as little as he can. It’s my belief they get their
notions from the daily papers—hear too much of all that’s goin’ on—it
onsettles them; they read about this Sawcialism, an’ these millioneers; it
makes a pudden’ in their heads. Look at the beer that’s drunk about it. For
one gallon that was drunk when I was young there’s twenty gallon now. The
very sheep ha’ changed since I remember; not one o’ them ewes you see
before you there, that isn’t pedigree—and the care that’s taken o’ them!
They’d have me think that men’s improvin’, too; richer they may be, but
what’s the use o’ riches if your wants are bigger than your purse? A man’s
riches is the things he does without an’ never misses.”
And crouching on his knee, he added:
“Ther’ goes the last o’ them; sha’n’t get ’em out now till tew o’clock.
One gone—all go!”
Then squatting down, as though responsibility were at an end, he leaned
one elbow on the grass, his eyes screwed up against the sun. And in his old
brown face, with its myriad wrinkles and square chin, there was a queer
contentment, as though approving the perversity of sheep.
“So riches don’t consist in man’s possessions, but in what he doesn’t
want? You are an enemy of progress?”
“These Downs don’t change—’tis only man that changes; what good’s
he doin’, that’s what I ask meself—he’s makin’ wants as fast as ever he
makes riches.”
“Surely a time must come when he will see that to be really rich his
supply must be in excess of his demand? When he sees that, he will go on
making riches, but control his wants.”
He paused to see if there were any meaning in such words, then
answered:
“On these Downs I been, man an’ boy, for sixty year.”
“And are you happy?”
He wrinkled up his brows and smiled.
“What age d’ you think I am? Seventy-six!”
“You look as if you’d live to be a hundred.”
“Can’t expect it! My health’s good though, ’cept for these.”
Like wind-bent boughs all the fingers of both his hands from the top
joint to the tip were warped towards the thumb.
“Looks funny! But I don’t feel ’em. What you don’t feel don’t trouble
you.”
“What caused it?”
“Rheumatiz! I don’t make nothin’ of it. Where there’s doctors there’s
disease.”
“Then you think we make our ailments, too, as fast as we make
remedies?”
He slowly passed his gnarled hand over the short grass.
“My missus ’ad the doctor when she died.... See that dust? That’s
motorcars bringin’ folks to Goodwood Races. Wonderful quick-travellin’
things.”
“Ah! That was a fine invention, surely?”
“There’s some believes in them. But if they folk weren’t doin’
everything and goin’ everywhere at once, there’d be no need for them
rampagin’ motors.”
“Have you ever been in one yourself?”
His eyes began to twinkle mockingly.
“I’d like to get one here on a snowy winter’s day, when ye’ve to find
your way by sound and smell; there’s things up here they wouldn’t make so
free with. They say from London ye can get to anywhere. But there’s things
no man can ride away from. Downs ’ll be left when they’re all gone....
Never been off the Downs meself.”
“Don’t you ever feel you’d like to go?”
“There isn’t not hardly one as knows what these Downs are. I see the
young men growin’ up, but they won’t stay on ’em; I see folk comin’ down,
same as yourself, to look at ’em.”
“What are they, then—these Downs?”
His little eyes, that saw so vastly better than my eyes, deepened in his
walnut-coloured face. Fixed on those grey-green Downs, that reigned
serene above the country spread below in all its little fields, and woods, and
villages, they answered for him. It was long before he spoke.
“Healthiest spot in England!... Talkin’ you was of progress; but look at
bacon—four times the price now that ever it was when I were young. And
families—thirteen we had, my missus and meself; nowadays if they have
three or four it’s as much as ever they’ll put up with. The country’s
changed.”

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The ADA Practical Guide to Effective

Infection Prevention and Control 5th

ADA Dental Drug Handbook A Quick Reference 2019th

Managing the Dental Team Guidelines for Practice

Creating and Updating an Employee Policy Manual

Fluoridation Facts 1st Edition American Dental

Managing Patients the Patient Experience Guidelines for

The ADA Practical Guide to Dental Implants 1st Edition

How to Use Evidence Based Dental Practices to Improve

Infection Control and Management of Hazardous Materials

American Dental Association

The Council on Dental Practice Mission

Chapter 2: Disinfection and Sterilization

Chapter 3: Dental Water Quality

Chapter 4: Infection Prevention and Control

Chapter 5: Special Considerations and

Chapter Review Questions

This book includes access to the ADA Practical Guide to Effective

In 1987, Congress directed the Department of Labor Occupational

COVID-19 Pandemic and Federal

Building a Culture of Safety

A culture of safety means that infection prevention and

Chapter Fundamentals of Infection Prevention

Disinfection and Sterilization provides

Dental Water Quality provides guidance

Chapter Infection Prevention and Control during

Special Considerations and Pandemic

The guide also contains:

• The kinds of personal protective equipment (PPE) that should

• The importance of immunization against infection.

• The importance of infection prevention measures to contain

• Strategies such as respiratory hygiene and cough etiquette,

• The limitations of the medical history in identifying individuals

• Standard Precautions (SP) and Universal Precautions (UP) for

• Policies for the detection and referral of patients who might

• Infection prevention practices necessary before, during, and

• The elements of instrument and materials management,

• The criteria for determining which items are reusable and

• Spaulding’s criteria for disinfection and sterilization of reusable

• How to select and implement appropriate cleaning,

• Appropriate procedures for safe storage, labeling, and handling

• The principles and practice of sterility assurance, including the

• What constitutes a bloodborne pathogens exposure incident

• How to develop and implement policies and practices to reduce

• Recommended practices for donning and removing PPE and

• Medical conditions and work-related illnesses that may require

• Policies and procedures to ensure appropriate hand hygiene

• The distinction between surgical, nonsurgical, and endodontic

• How to maintain dental unit water quality according to

• How to appropriately handle and dispose of regulated and

• How to safely decontaminate, disinfect, and transport or ship

• The importance of establishing standard operating procedures

How to Use This Book

To Use This Guide

Continuing Education Credit

Infection Prevention and Control

Which of the following dental treatment facility

• An Infection Prevention and Control (IPC) Coordinator

• IPC, OSH, and pandemic/emergency preparedness

• All DHCP receive IPC, OSH, and pandemic/emergency

Before seating the patient and beginning clinical

• Use the same infection prevention and control

• Protect dental records, charts, radiographs, and digital