ADA 2021 Infection Control Guidelines PDF

Guidelines for Infection Prevention and Control Fourth Edition Guidelines for Infection Prevention and Control Fourth Edition ©2021 Authorised by Dr Mark Hutton, President, Australian Dental Association Published by the Australian Dental Association PO Box 520 St Leonards NSW 1590 Australia Phone...

Guidelines for Infection Prevention and Control Fourth Edition Guidelines for Infection Prevention and Control Fourth Edition ©2021 Authorised by Dr Mark Hutton, President, Australian Dental Association Published by the Australian Dental Association PO Box 520 St Leonards NSW 1590 Australia Phone: +612 8815 3333 Email: [email protected] Web: www.ada.org.au Imagery provided by Professor Laurie Walsh, Getty Images and Dental Stock Photos: www.dentalstockphotos.com ©Australian Dental Association 2021 First Published 2009, Second Edition 2012, Third Edition 2015 This work is copyright. Apart from any permitted use under the Copyright Act 1968, no part of this work may be reproduced by any process without written permission from the publisher. Enquiries should be directed to the Australian Dental Association at the above address. Disclaimer: The routine work practices outlined in these Guidelines are designed to reduce the number of infectious agents in the dental practice environment, prevent or reduce the likelihood of transmission of these infectious agents from one person or item/ location to another, and make items and areas as free as possible from infectious agents. Professional judgement is essential in determining the necessary application of these Guidelines to the particular circumstances of each individual dental practice. ISBN: 978-0-646-84312-4 Foreword This fourth edition of the Australian Dental Association (ADA) new element of infection prevention and control practice included Guidelines for Infection Prevention and Control incorporates in this document and incorporate these changes into daily work a number of changes that have arisen since the publication practices. These changes will also need to be reflected in each of the third edition in 2015. Primarily this includes updates practice’s infection prevention and control manual. of the Australian National Guidelines for the Management of The production of this document has required considerable effort Health Care Workers Known to be Infected with Blood-Borne over a long period of time. In developing the 4th Edition, the Viruses from the Communicable Diseases Network of Australia ADA actively sought input from a broad range of stakeholders (CDNA) published in 2018 and the Australian Guidelines for including the Dental Board of Australia, the NSW Dental Council the Prevention and Control of Infection in Healthcare from the as well as peak dental professional bodies, namely, the Dental National Health and Medical Research Council (NHMRC) published Hygienists Association of Australia, the Australian Dental and Oral in 2019, as well as amendments to Australian standards related Health Therapists Association, the Australian Dental Prosthetists to infection prevention and control. The fourth edition contains Association and the Dental Assisting Professional Association. some reference to infection prevention and control learnings as a Special thanks and acknowledgment are due to the current and result of the COVID-19 pandemic. As further evidence emerges, former members of the ADA’s Infection Control Committee (ICC) it is anticipated that supplementary information will be made and in particular Professor Laurie Walsh AO, the 2021 ICC chair, available. who has been instrumental in the revision of this document. This ongoing process of revision follows a commitment by Other members of the Committee include: the ADA to follow contemporary Australian Guidelines and to Associate Professor Sharon Liberali (ICC Chair 2020) align with current international best practice in evidence-based Dr Brendan White (Vice Chair) infection prevention and control. These Infection Prevention and Control Guidelines will continue to be updated periodically to Dr Kate Amos ensure they remain contemporary and evidence-based. Dr Martin Lavery These Guidelines are the result of more than 30 years of dedicated Dr Heidi Munchenberg work by the members of the ADA’s Infection Control Committee Dr Martin Webb and input from key stakeholders. The ADA Infection Control Dr Greg Whiteley. Committee is comprised of registered dentists, dental specialists and non-dentists who are experts in infection prevention In addition, we acknowledge the significant contribution from the and control in clinical dental practice, and who work in the ADA Federal office, ADA Branches and other dental professional public sector, private sector and tertiary education settings. bodies who have contributed time, technical advice and expertise They represent the dental profession on national committees in preparing this document. developing infection prevention and control standards including the NHMRC, the Communicable Disease Network of Australia, subcommittees supporting the National COVID-19 Clinical Evidence Taskforce, the National Clinical Taskforce, and Standards Australia. Dr R Mark Hutton In 2020, documents developed by the Committee were reviewed by the Chair of the Federal Infection Control Expert Group (ICEG) Federal President prior to being endorsed by the Australian Health Protection Principal Committee (AHPPC). They were subsequently referenced by the Australian Commission on Safety and Quality in Healthcare and the Dental Board of Australia in providing guidance to the dental profession. The ADA’s Guidelines for Infection Prevention and Control has been recognised as a key source of information for the NHMRC Guidelines and at the time of finalisation (May 2021) is identified by the Dental Board of Australia (DBA) as a mandatory resource for dental practitioners. It was also used as the major reference source for the New Zealand Dental Council’s 2016 Infection Prevention and Control Practice Standard. It is important that every registered dental practitioner and all members of the dental team familiarise themselves with each Contents Supporting and reference documents 6 6. Environment 26 Key compliance points for applying the Design of premises 26 guidelines to your clinical practice setting 7 Key compliance points for environment 27 Section A. Infection prevention and control 10 Cleaning the environment 27 1. What is infection prevention and control? 10 Treatment areas 28 Standard Precautions (see Section B for further details) 11 Key compliance points for environmental cleaning 28 Transmission-based precautions 11 Section C. Infection prevention and control Key compliance points for reducing strategies within the contaminated zone 29 the spread of infection 12 1. Clean and contaminated zones 29 2. Legislative frameworks 12 Key compliance points for clean and 3. Duty of care 13 contaminated zones 30 Key compliance points for documentation 14 2. Waterlines and water quality 30 4. Treating patients with BBV infections 14 Water quality 30 5. Infected dental practitioners 14 Key compliance elements for waterlines 31 Key compliance points for BBV disease status 15 3. Single-use items 31 Key compliance elements for single-use items 31 Section B. Standard precautions for infection prevention and control 16 4. Matrix bands 31 1. Hand hygiene 16 5. Burs 32 When to perform hand hygiene 16 6. Implant hardware 32 How to apply ABHR for regular hand hygiene 16 Section D. Instrument reprocessing 33 How to select an appropriate ABHR product 16 1. Categories of instruments: Infection risk Location of hand gel dispensers 17 relative to instrument use 33 Use of moisturiser 17 Critical Items 33 When is handwashing needed, rather than ABHR? 17 Semi-critical Items 33 Hand care 18 Non-critical Items 34 Appropriate preparation of the hands and Key compliance items for the Spaulding classification 34 wrists – ‘bare below the elbows’ 18 2. Instrument reprocessing area and workflow 34 Key compliance points for ‘bare below the elbows’ 19 Design of the reprocessing area 34 2. Personal protective equipment (PPE) 19 3. Transfer of contaminated instruments and sharps 35 Gloves 19 4. Cleaning 35 Key compliance points for gloves 21 PPE requirements during instrument cleaning 35 Masks 21 Pre-cleaning at the chairside 35 Key compliance points for masks 22 Procedure for delayed cleaning 36 Eye protection 22 Rinsing prior to cleaning 36 Key compliance points for eyewear 23 Mechanical cleaning 36 Protective clothing 23 Manual cleaning 37 Footwear 24 Rinsing after ultrasonic cleaning or manual cleaning 37 Key compliance points for protective clothing Drying instruments 37 and footwear 24 Inspection 38 3. Surgical procedures and surgical aseptic technique 24 5. Packaging prior to steam sterilisation 38 Key compliance points for surgical procedures 24 6. Batch Control Identification (BCI) 39 4. Management of sharps 25 Including batch code data within steriliser cycle records 40 Disposal of sharps 25 Key compliance items for reprocessing stages prior Key compliance points for sharps handling and disposal 26 to sterilisation 40 5. Management of clinical waste 26 7. Sterilisation using steam 41 Key compliance points for waste 26 8. Maintenance and testing 41 Section F. Special areas and their particular dental Verification of the sterilisation process 41 infection prevention and control requirements 54 Monitoring of cycles 41 1. Dental radiology and photography 54 Operating the steam steriliser 42 2. Specialised intra-oral equipment and devices 54 9. Steam steriliser performance tests 42 Curing light 55 Loading 43 Air abrasion, electrosurgery units, and lasers 55 Drying 43 3. Implants 56 Checking the completed load 43 4. Impressions 56 Visual inspection of sterilised wrapped items 43 5. Dental laboratory and dental prosthetics 56 Retention of cycle data from steam sterilisers 44 6. Handpiece management 56 Key compliance items for sterilisation using steam 44 7. Specimens 57 10. Steam steriliser monitoring tests 44 8. Endodontic irrigants 57 Chemical indicators 44 9. Gutta percha points 57 Storage and use of chemical indicators 46 10. Hand-operated endodontic files 57 Key compliance items for chemical indicators 46 11. Rotary nickel-titanium (NiTi) endodontic files 58 Biological indicators 46 12. Relative analgesia equipment 58 Qualification and validation 46 13. Nursing home visits 58 Key compliance items for biological indicators 47 Key compliance items for special areas 58 11. Disinfection 47 Section G. Infectious diseases, allergies, and Thermal disinfection using washer disinfectors 47 transmission-based precautions for infection Chemical disinfection using instrument disinfectants prevention and control 59 – high-level (instrument-level) 48 1. Prion diseases including Creutzfeldt-Jakob disease (CJD) 59 Supporting and reference documents 48 2. Measles, mumps, and tuberculosis 59 Key compliance items for disinfection 48 3. Human viral influenza 59 Surface disinfectants and disinfectant wipes 48 4. Avian influenza viruses 60 Key compliance items for disinfection 48 5. Staphylococcus aureus 60 12. Storage of processed instruments 48 Key compliance items for Key compliance items for storage of transmission-based precautions 60 processed instruments 49 6. Allergies to chlorhexidine 60 7. Latex sensitivity 60 Section E. Documentation and practice protocols for infection prevention and control 50 Key compliance items for allergies and sensitivity 61 1. Maintaining records of instrument reprocessing 50 Appendix 1. Blood and body fluid exposure protocol 62 Other documentation for the steam steriliser 50 First aid 62 Key compliance items for documentation of Risk assessment 62 sterilisation processes 50 Testing 62 2. Infection prevention and control for Baseline tests 62 dental practitioners and clinical support staff 50 Testing the source patient 63 Immunisation 50 Refusal for testing 63 Immunisation records 51 Source negative 63 Key compliance items for immunisation 51 Source positive for hepatitis B 63 Education 51 Source positive for hepatitis C 63 3. Exposure incident protocol 52 Source positive for HIV 63 Key compliance items for education 52 Testing for the injured person 64 4. Infection prevention and control manual and other practice management issues 52 Appendix 2. Frequently Asked Questions 65 5. Infection control manual 53 Key compliance items for infection control manual 53 Introduction When applying for or renewing their registration, all dental Responsibility for infection prevention and control compliance practitioners undertake to comply with all relevant state and rests with each registered dental practitioner and cannot be commonwealth legislation related to their practice. Most notably, delegated. Failure to comply with the Board’s Guidelines may lead they confirm that they will comply with the Dental Board of to a practitioner’s conduct being investigated by the DBA or by a Australia (DBA) registration standards, codes, and Guidelines, and public health regulator in the jurisdiction in which they practice. this includes the Board’s current Guidelines on Infection Control. As regulators are frequently tasked with determining if conduct In Australia, a combination of Guidelines, standards and manuals falls substantially below an appropriate standard, such consensus underpin requirements for infection prevention and control documents have an important role to play as a clear reflection of practices. In most instances, these documents are formed for professional expectations. Therefore, each dental practitioner must broader health or hospital settings rather than dentistry in ensure that they fulfil their obligations to practise in a safe and particular. The ADA’s Guidelines for Infection Prevention and hygienic manner in accordance with the guidelines. This includes a Control serves to synthesise current requirements into a resource responsibility to ensure that support staff have dedicated infection that can be readily applied by dental practitioners and their prevention control procedures in place in alignment with the teams in the dental setting specifically. The ADA’s Guidelines for ADA’s Infection Prevention and Control Guidelines, and ongoing Infection Prevention and Control is published freely by the ADA training to ensure consistent implementation. for all dental practitioners, as is appropriate for a document referenced directly by the DBA Infection Control Guidelines, in the interest of public safety standards. The ADA Guidelines for Infection Prevention and Control is a key resource to guide practitioners in applying complex documentation in a practical way that acknowledges the specific challenges of the dental environment. It reflects a shared interest of regulators and the ADA to ensure public safety is at the forefront of our profession through clarity, accessibility and consensus in our professional practices. The ADA Guidelines for Infection Prevention and Control describe the infection prevention and control procedures that dental practitioners and their clinical support staff are expected to follow in a dental practice. The document outlines the primary responsibilities of practitioners and the rationale for those obligations, the routine work practices designed to reduce the number of infectious agents in the dental practice environment, ways to prevent or reduce the likelihood of transmission of these infectious agents from one person or item/location to another, and methods to make items and areas as free as possible from infectious agents. Professional judgement is essential in determining the application of these Guidelines to the situation of the individual dental practice environment. Greater details on key technical aspects are provided in the ADA’s Practical Guide to Infection Control, which provides supporting scientific references that underpin the guidelines. Where no evidence base is available for issues specific to dental practice, these Guidelines draw upon current international best practice and expert knowledge and advice in infection prevention and control. These Guidelines will be reviewed and updated in light of changes in the evidence and knowledge base. Guidelines for Infection Control | 6 Supporting and reference documents In these Guidelines, where key details reside in external At the time of writing (May 2021), both AS/NZS 4815:2006 and documents, those references are listed in the footer of each page AS/NZS 4187:2014 are current. It is anticipated that in 2022, in which they are cited, and can be directly accessed for further a new Australian and New Zealand standard will be published information. that covers both office-based practice and large health care The ADA’s Infection Prevention and Control Guidelines are facilities. This new standard will have a new number. Until the informed by the following key reference documents: new standard is published, dental practitioners should continue to follow the Standards appropriate to their type of practice. Dental Board of Australia Guidelines on Infection Control (2010). Australian Guidelines for the Prevention and Control of Key compliance points for applying the guidelines to Infection in Healthcare (NHMRC 2019). your clinical practice setting AS/NZS 4815:2006 Office-based health care facilities – Identify which of the two current Australian Reprocessing of reusable medical and surgical instruments instrument reprocessing standards (AS/NZS 4187 or and equipment, and maintenance of the associated AS/NZS 4815) you will follow. environment and AS/NZS 4187:2014 (Amendment 2, 2019) Maintain access to copies of the key reference Reprocessing of reusable medical devices in health service documents listed above. organisations. Update your dental practice infection prevention The National Hand Hygiene Initiative. and control protocols to ensure that they align with National Guidelines for the Management of Healthcare the content in this edition of the ADA Guidelines for Workers Living with Blood Borne Viruses Who Perform Infection Control. Exposure Prone Procedures (CDNA 2018). Apply professional judgement when determining how it applies to your individual dental practice The NHMRC Guidelines describe the principles of infection environment. prevention and control that apply across all healthcare settings, including dental practice. They also provide specific advice on situations where additional risks exist such that transmission-based precautions are warranted. The two standards from Standards Australia that are relevant to instrument reprocessing in dental practice are the Australian and New Zealand Standards AS/NZS 4815:2006 Office-based health care facilities – Reprocessing of reusable medical and surgical instruments and equipment, and maintenance of the associated environment and AS/NZS 4187:2014 Cleaning, disinfecting, and sterilising reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities. According to the DBA’s Guidelines on Infection Control, dental practitioners work under AS/NZS 4815:2006, unless they work within an organisation that operates under AS/NZS 4187:2014. General practice dental clinics should follow AS/NZS 4815:2006, as it is relevant to office-based dental practice. AS/NZS 4187:2014 (as amended in 2018 and 2019) covers health service organisations (HSO) such as hospitals and day procedure centres. It discusses the reprocessing requirements of complex patient procedures. The current version of AS/NZS 4187:2014 makes extensive reference to international standards that apply to aspects of instrument reprocessing and global guidelines, such as those from the International Organization for Standardization (ISO). Guidelines for Infection Control | 7 Glossary & Definitions ACSQHC: The Australian Commission on Safety and Quality in Dental Board: refers to the Dental Board of Australia (DBA). Health Care. ACSQHC leads and coordinates key improvements in Dental Practitioner: is an inclusive term that refers to those safety and quality in health care across Australia. registered by the DBA to provide clinical dental care to patients, AGP: Aerosol generating procedure. and comprises general dentists, dental specialists, dental AS or AS/NZS: refers to the Australian and/or Australian and New prosthetists, dental therapists, dental hygienists, and oral Zealand standards, as produced by Standards Australia. These health therapists. are referred to as either AS or AS/NZS followed by the relevant Dental Staff: is an inclusive term for all those employed in a standard number and the year of publication. dental practice setting – namely, dental practitioners, clinical Alcohol-based Hand Rub (ABHR): an alcohol-based gel or support staff, and clerical or administrative staff. solution that is intended to be used on the hands without the use Disinfectant: means a substance: of water in a hand rubbing procedure. a. that is recommended by its manufacturer for application Antibacterial Hand Wash: a detergent-based formulation to an inanimate object to kill microorganisms; and intended to be used with water in a handwashing procedure. b. that is not represented by the manufacturer to be Australian Register of Therapeutic Goods (ARTG): this is the suitable for internal use. register of all therapeutic goods which is maintained in real time Disinfection: is the destruction of pathogenic and other kinds of by the TGA. It is accessible via the TGA web portal. microorganisms by physical or chemical means. Autoclave: a device used to achieve steam sterilisation. Exposure Incident: is any incident where a contaminated Bare Below the Elbow: all hand, wrist, or nail jewellery (e.g., object or substance breaches the integrity of the skin or mucous rings with stones or non-smooth surfaces, bangles and bracelets), membranes or comes into contact with the eyes. watches, and wearable devices such as ‘Fitbits’, must be removed Exposure Prone Procedures (EPPs): are procedures where by clinical staff prior to putting on gloves, as their presence there is a risk of injury to dental staff resulting in exposure of impairs correct handwashing, compromises the fit and integrity of the patient’s open tissues to the blood of the staff member. EPPs gloves, and promotes the growth of skin microorganisms. are defined in the 2018 edition of the CDNA Australian National Batch Control Identification (BCI): also referred to as tracking, Guidelines for the Management of Health Care Workers Known is the ability to link a patient procedure involving critical items to be Infected with Blood-Borne Viruses as procedures where the back to the records for a specific steriliser cycle. This is done fingertips are out of sight for a significant part of the procedure, for a set, package, or cassette of instruments, by transferring or during certain critical stages, and in which there is a distinct risk batch information from the label into the patient’s record for of injury to the Health Care Worker’s (HCW) gloved hands from that appointment. This includes the date of processing, cycle or sharp instruments, needle tips, and/or sharp tissues, including load number, and if more than one steam steriliser is in use, its spicules of bone or teeth. In such circumstances, it is possible that identification number. exposure of the patient’s open tissues to the HCW’s blood may go Blood-borne Viruses (BBVs): include hepatitis B virus (HBV), unnoticed or would not be noticed immediately. Such procedures hepatitis C virus (HCV), and human immunodeficiency virus (HIV). include maxillofacial surgery and oral surgical procedures, These viruses are transmitted primarily by blood-to-blood contact. including the extraction of teeth (but excluding extraction of highly mobile or exfoliating teeth), periodontal surgical Bowie-Dick Test: a challenge test that assesses air removal and procedures, endodontic surgical procedures, and implant surgical steam penetration for porous loads. procedures. Other procedures undertaken in dentistry would not CDNA: Communicable Diseases Network Australia provides normally be regarded as EPPs because the hands and fingertips national public health co-ordination and leadership and supports of the HCW are usually visible and outside the body most of the best practice for the prevention and control of communicable time and the possibility of injury to the worker’s gloved hands diseases. from sharp instruments and/or tissues is unlikely. If injury occurs, it Clinical Support Staff Members: are those staff, other than is likely to be noticed and acted upon quickly to avoid the HCW’s registered dental practitioners, who assist in the provision of blood contaminating the patient’s open tissues. dental services – including but not limited to, dental assistants, Fit check: a test performed each time a dental practitioner puts dental laboratory assistants, sterilising/reprocessing assistants, and on a P2 respirator to make sure it is properly applied. dental technicians. It is recognised that some individuals may have Fit test: identification of which size and style of P2 respirator is both clinical and administrative roles. suitable for an individual, usually by a trained operator. Contaminated Zone: is that area of work in which direct Hand Wash: hand hygiene that uses water. contamination by patient fluids (blood and body fluids, including saliva) may occur by transfer, splashing, or splatter of material. It Hand Rub: hand hygiene that does not use water. includes the operating field in the dental operatory, as well as the HCW: health care worker. instrument cleaning area within the reprocessing room. Guidelines for Infection Control | 8 Helix Test: used to test air removal and steam penetration in hollow loads. Infection Prevention and Control: the creation of safe healthcare environments through the implementation of evidence based practices that minimise the risk of transmission of infectious agents (NHMRC, 2019). NHMRC: the National Health and Medical Research Council is an expert body supporting the translation of health and medical research into better health outcomes and promotion of the highest standards of ethics and integrity in health and medical research. Penetrating Injury: is any injury from a sharp object such as an injection needle, scalpel blade, dental bur, or denture clasp contaminated with a patient’s blood or saliva. PPE: Personal Protective Equipment. Steam Steriliser: device used widely for sterilising instruments in office-based dental practices; otherwise known as an Autoclave. Standard Aseptic Technique: the infection prevention and control strategies applied to all non-surgical procedures in dentistry where transmission-based precautions are not required. This includes the use of gloves, items of personal protective equipment, and rigorous hand hygiene practices. Sterilant: a process which achieves a sterility assurance level of 10-6 [1 in 1 million]. Surgical Aseptic Technique: applied to all surgical procedures and consists of additional precautions including the use of sterile gloves, surgical hand hygiene, sterile drapes, and irrigation solutions and instruments that are sterile at the point of use (with batch control identification). TGA: Therapeutic Goods Administration. Transmission-based Precautions: additional infection prevention and control measures which add to the standard precautions. These are tailored to the mode of transfer [contact/ droplet/airborne] specific to the infectious agent concerned. Guidelines for Infection Control | 9 Section A. Infection prevention and control 1. What is infection prevention and control? do not remain suspended in the air indefinitely but settle onto surfaces because of the influence of gravity. The purpose of infection prevention and control in dental practice is to prevent/minimise the transmission of disease-producing Droplet transmission can occur when hands become agents such as bacteria, viruses, and fungi from one patient to contaminated with respiratory droplets and transferred to another, from dental practitioners and dental staff to patients, and susceptible mucosal surfaces such as the eyes, or when infectious from patients to dental practitioners and/or other dental staff. In respiratory droplets are expelled by coughing, sneezing, or talking addition, infection prevention and control also involves measures and come into contact with another person’s mucosa (eyes, nose, that limit the spread of infectious agents. or mouth), either directly or via contaminated hands. Successful infection prevention and control involves: There is good evidence that viral influenza and certain other respiratory infections can spread via droplets. This has implications understanding the basic principles of infection prevention in terms of how far away to position clean items, such as open and control; boxes of gloves, from the patient’s mouth. A separation distance creating systems that allow infection prevention and of 1.829 m (6 feet) has been recommended for medical staff who control procedures to be implemented effectively and to are examining patients with suspected influenza.1 make compliance with them easy (this includes having clear procedural documentation and comprehensive and This distance of 1.829 m also serves as a useful evidence-based ongoing training of dental staff, together with a process of measure of how far particles from a cough or sneeze may travel regular monitoring of the application of these systems and forward, in a straight line, when expelled from the mouth. It is procedures); prudent that supplies of clean items (including open glove boxes) should be no closer than this distance from the patient’s mouth keeping up to date regarding new or re-emerging infectious if they are situated directly in front of the dental chair. A forward diseases, particularly newly evolving strains of human separation distance of 1.829 m will prevent these items from influenza viruses and multiple antibiotic-resistant organisms, being contaminated with droplets expelled from the patient’s and how to take precautions against them; and mouth, should the patient cough or sneeze. identifying settings and situations that require modified Whether or not the spread of microorganisms results in clinical infection prevention and control procedures (e.g., when infection depends in part on the virulence (power to infect) of a performing dental care when mobility is restricted, in a particular microorganism and on the susceptibility of the host. patient’s home, or at a residential aged care facility). As explained in the 2018 CDNA Guidelines, hepatitis B virus The DBA stipulates that dental practitioners ‘must practise in (HBV) is highly infectious and the chance that this disease will a way that maintains and enhances public health and safety be transmitted by a contaminated penetrating injury to a non- by ensuring that the risk of the spread of infectious diseases is immune dental staff member is on average approximately 30%, prevented or minimised. Dental practitioners must ensure that the but may range from as low as 1% to as high as 62%, depending premises in which they practise are kept in a clean and hygienic on the infective status of the source patient. In comparison, the state to prevent or minimise the spread of infectious diseases and chance of transmission of the hepatitis C virus (HCV) by similar that, in attending a patient, they take such steps as are practicable means is approximately 3% on average (but may range up to to prevent or minimise the spread of infectious diseases’. 7%), and for HIV/AIDS, the risk of transmission from an infected In dental practice, microorganisms may be inhaled, implanted, patient to a HCW is on average 0.3% (1 in 300). ingested, injected, or splashed onto the skin or mucosa. They can Patients and dental staff have varying susceptibilities to infection spread by direct contact from one person to another, or through depending on their age, state of health, underlying illnesses, and indirect contact via instruments and equipment, such as when a immune status (which may be impaired by medication, disease, dental staff member’s hands or clothing become contaminated, cancer therapy, and other factors such as malnutrition and when patient care devices are shared between patients, when hormone deficiency). infectious patients have had contact with other patients, or when Infection prevention and control focuses on limiting or controlling environmental surfaces are not regularly decontaminated. factors that influence the transmission of infection or contribute In the dental practice setting, microorganisms can also spread by to the spread of microorganisms. The spread of microorganisms airborne transmission – when dental staff or others inhale small can be reduced by: particles containing infectious agents. A number of infectious limiting surface contamination by microorganisms; agents, including human viral influenza, can be transmitted through airborne particles generated by a person who is adhering to good personal hygiene practices, particularly coughing, sneezing, or talking. Transmission via large droplets effective hand hygiene and cough etiquette; (splash and splatter) requires close contact, as large droplets using PPE correctly; Guidelines for Infection Control | 10  using disposable products where appropriate (e.g., paper in a patient’s mouth), when handling blood (including dried towels); and blood), saliva, and other body fluids (excluding sweat), whether following risk minimisation techniques such as the use of containing visible blood or not, and when cleaning and processing high-volume evacuation, dental dam and pre-procedural instruments. mouth rinsing. In some circumstances, patients have a specific, highly infectious condition that necessitates the use of transmission-based Standard Precautions (see Section B for further details) precautions in addition to standard precautions, in order to Standard precautions are the basic processes of infection address the increased risk of transmission. prevention and control used to minimise the risk of transmission of infection. They include: Transmission-based precautions undertaking regular hand hygiene [5 moments: before Transmission-based (risk-based) precautions are applied when touching a patient, before a procedure, after a procedure, patients are suspected or confirmed to be infected with agents after touching a patient, after touching a patient’s transmitted by contact, droplet, or airborne routes. The agents of surroundings (including their belongings)], before gloving most concern to dental practice are respiratory viruses. [donning] and after glove removal [doffing], and at other The range of measures used in transmission-based precautions ‘moments’ or opportunities when transmission of infection depends on the route(s) of transmission of the infectious agent. may occur; The application of transmission-based precautions is particularly using personal protective barriers such as gloves, masks, eye important in containing multi-resistant organisms (MROs) in protection, and gowns; hospital environments and in the management of outbreaks of norovirus gastroenteritis in institutions such as hospitals and wearing appropriate protective equipment during clinical nursing homes. procedures and when cleaning and reprocessing instruments; Details of the transmission-based precautions that are required for correctly handling contaminated waste; specific infectious diseases are given in the 2019 version of the appropriately handling sharps; Australian Guidelines for the Prevention and Control of Infection appropriately reprocessing reusable instruments; in Healthcare from the National Health and Medical Research effectively undertaking environmental cleaning; Council (NHMRC). In brief, transmission-based precautions are following respiratory hygiene and cough etiquette; used when there is a risk of direct or indirect contact transmission of infectious agents (e.g., viral influenza, MRSA, Clostridium using the correct aseptic non-touch technique where difficile, or highly contagious skin infections or infestations) that indicated; are not effectively contained by standard precautions. appropriately handling used linen and clinical gowns; and Droplet precautions are intended to prevent transmission of using, where appropriate, single-use environmental barriers infectious agents through respiratory or mucous membrane such as plastic coverings on surfaces and items that may contact with respiratory secretions. These microorganisms do not become contaminated and are difficult to clean. This travel over long distances in droplet form due to their size (larger includes when the use of a barrier has been stipulated by the than 5 microns). manufacturer of the piece of equipment. Airborne precautions, which include the use of P2 (N95) These standard precautions minimise the risk of transmission surgical respirators, are designed to reduce the likelihood of of infection from person to person and are required for the transmission of microorganisms that remain infectious over treatment of all dental patients regardless of whether a particular time and distance which remain suspended in the air for longer patient is infected with or is a carrier of an infectious disease. periods of time due to their small size (less than 5 microns). These They apply to all situations whenever dental practitioners or their agents may be inhaled by susceptible individuals who have not clinical support staff touch the mucous membranes or non-intact had face-to-face contact with (or been in the same room as) skin of a dental patient. the infectious individual. Infectious agents for which airborne Standard precautions are also essential when cleaning the dental precautions are indicated include measles, chickenpox (varicella), surgery environment, when handling items contaminated with and Mycobacterium tuberculosis, as well as novel respiratory saliva (e.g., radiographic films or sensors, dentures, orthodontic pathogens such as H5N1 influenza, avian influenza, and certain appliances, wax rims, and other prosthetic work that have been coronavirus infections. 1. Bischoff WE, Swett K, Leng I, Peters RF. Exposure to influenza virus aerosols during routine patient care. J Infect Dis, 2013;207:1037-1046. Guidelines for Infection Control | 11 There is strong evidence to support and recommend the use 1. the patient is seen as the last patient of the day; of negatively pressurised rooms for patients who are at risk of 2. ensuring that staff providing treatment have been immunised transmitting infectious organisms via the airborne route. This against the current circulating influenza strains; means that patient care under airborne precautions is often not 3. use of a pre-procedural mouth rinse; possible in a private small office practice setting (unless special modifications have been made to the airconditioning plant and 4. use of a dental dam for restorative procedures; approved by an appropriately trained engineer). For effective 5. minimising the use of aerosol-generating techniques; airborne precautions, a P2 (N95) surgical respirator is required, 6. applying two complete cycles of cleaning for environmental which forms an airtight seal with the face. In order to be effective, surfaces; and these respirators must be fit tested at regular intervals, and then 7. If the patient is seen during the day, allowing 30 minutes of fit checked at the time of each use. HCWs with facial hair must be fallow-time before the room is used for further procedures on aware that this prevents the formation of an airtight seal between the same day. the respirator and the facial skin. There will be few situations encountered where the dental At present, there is a lack of evidence from clinical trials regarding emergency is such that analgesics and other conservative the additional benefits of P2 (N95) respirators over conventional measures will not allow a temporary delay in dental treatment surgical masks for reducing the risk of transmission of viral until the patient is no longer infectious. influenza. A surgical mask that is sealed tightly to the face has been shown to block entry of 95% of total influenza virus 2. Legislative frameworks particles, while a tightly sealed N95 surgical respirator can block Registered dental practitioners are legally required to comply over 99% of virus particles. In contrast, a loosely fitted surgical with the DBA’s policies and guidelines. The responsibilities around mask blocks 56%, and a poorly fitted respirator only 66% of infection prevention and control are stipulated in the Dental Board infectious virus particles.2 In other words, a poorly fitted P2 (N95) of Australia’s Guidelines on Infection Control. surgical respirator does not perform as well as a tightly sealed As mentioned previously, these responsibilities cannot be surgical mask. This is why fit testing and fit checking is essential delegated to dental assistants, practice managers, or practice for surgical respirators. owners. Rather, each registered dental practitioner must ensure The majority of procedures undertaken in dentistry generate that they fulfil their obligations to practise in a safe and hygienic aerosols (AGPs). Some items of equipment are more likely to manner. generate intense aerosols, such as ultrasonic scalers and high- speed air turbine handpieces. Therefore, it is important to recognise that patients with viral influenza, active tuberculosis, Key compliance points for reducing the spread of measles, or chickenpox pose a considerable risk to dental staff infection and to other patients if they undergo dental treatment. For Locate open boxes of gloves and masks away from patients for whom airborne precautions are indicated, a formal where contamination is likely to occur. risk assessment should be undertaken to determine the need for Minimise the number of items of equipment and dental treatment. Non-urgent treatment should be delayed or the amount of consumable supplies that are kept on postponed. benchtops in the operatory. Patients with viral influenza should not have elective dental Minimise the number of items of equipment in the treatment while they are infectious (two weeks for a patient aged operatory that are located beside the patient’s head or 13 years and above, three weeks after symptoms develop for directly in front of the dental chair (facing toward the patients aged 12 or less). patient’s feet) because these are likely locations for If patients with viral influenza require urgent care, transmission- contamination to occur. based precautions must be followed. The additional measures Apply risk-based precautions for patients with viral needed include: influenza. Consult the NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare for specific advice on other situations where additional risks are likely and where transmission-based precautions are required. 2. Noti JD, Lindsley WG, Blachere FM, Cao G, Kashon ML, Thewlis RE, et al. Detection of infectious influenza virus in cough aerosols generated in a simulate patient examination room. Clin Infect Dis. 2012;54:1569-1577. Guidelines for Infection Control | 12 It is essential for staff members to understand that the infection ensure an immunisation program for dental staff is in prevention and control policies of a dental practice reflect these place and is in accordance with the current edition of the legislative requirements, as well as other obligations of law, Australian Immunisation Handbook; including work health and safety legislation, which stipulates maintain an immunisation status record for each member the need to follow legal directions, including written safety of the dental staff (see Section E for a list of recommended instructions or directives from the employer (a term which immunisations); includes compliance with written infection prevention and control maintain a record of workplace incidents and accidents protocols). (including sharps injuries) as required by national WHS 3. Duty of care legislation; Dental practitioners have a common law legal duty of care to maintain an allergy record for each member of the their patients and must ensure that effective infection prevention dental staff; and control measures are in place and are complied with in implement specific training and education on the correct use the practice. Consequently, all dental practitioners and clinical of PPE; support staff have a responsibility to follow the specific infection implement a hand hygiene program consistent with the prevention and control policies that apply in their place of work. current version of the National Hand Hygiene Initiative, which All staff members have duties of care to themselves and to others promotes the use of ABHRs in situations where hands are not (in this case, other workers and patients of the practice) whose visibly contaminated; health and safety would be compromised by the staff member not implement systems for the safe handling and disposal of following correct procedures. Compliance of staff members with sharps; workplace protocols should be a key element of assessment of implement systems to prevent and manage occupational their performance. exposure to blood-borne viruses (BBVs); As mentioned previously, the DBA stipulates that dental implement systems for environmental cleaning; practitioners must take ‘such steps as are practicable to prevent or minimise the spread of infectious diseases’.3 implement systems for processing of reusable instruments and devices as per the relevant standard; Dental practitioners must: be aware of their immune status. Dental practitioners have ensure the premises in which they practise are kept in a a professional and ethical responsibility to know their status clean and hygienic state to prevent or minimise the spread of for BBVs. The DBA stipulates that all dental practitioners must infectious diseases; be aware of their infectious status for HBV, HCV, and HIV. develop and implement work practices to ensure compliance Information on the appropriate frequency of testing is based with infection prevention and control standards; on the nature of the work being done. The 2018 CDNA document their infection prevention and control protocols in Guidelines stipulate that all HCWs who perform exposure an infection prevention and control manual that is based on prone procedures (EPPs) should be tested at least once every the requirements set out in these Guidelines, in the NHMRC three years; 2019 Guidelines, and in the relevant Australian standard for not perform EPPs if viraemic for HBV, HCV, or HIV. There are instrument reprocessing; specific pathways documented in the 2018 CDNA Guidelines ensure that all dental staff have read the infection prevention for managing practitioners who are positive for HBV, HCV, or and control manual and have been trained in the infection HIV. Such individuals must seek expert medical advice; and prevention and control protocols used in the practice; follow through after potential exposures to BBVs, including provide their dental staff with access to key resources reporting the incident if it was an occupational exposure, such as these ADA Guidelines, the current edition of the undergoing testing, and if necessary, seeking specialist NHMRC Guidelines, and the most recent edition of the medical management. Note that it is not necessary for relevant standard for instrument reprocessing (e.g., AS/NZS practitioners to stop performing EPPs after an exposure 4815:2006 or AS/NZS 4187:2014 (as amended)); incident, unless baseline testing reveals that they are already have in place a system of reporting, monitoring, and infected with a BBV. rectifying breaches of infection prevention and control protocols (which would involve addressing this topic in staff meetings and recording the outcomes from such discussions); 3. See the Dental Board of Australia Guidelines on Infection Control, July 2010 (www.dentalboard.gov.au/Codes-Guidelines/Policies-Codes-Guidelines.aspx). Guidelines for Infection Control | 13 Under work health and safety (WHS) legislation in all Australian 5. Infected dental practitioners jurisdictions, practice owners have an obligation to provide and When applying for or renewing their registration, all dental maintain a safe working environment for employees and for practitioners must declare that they are aware of their infection members of the public. This means that practice owners must status for BBVs and will comply with the 2018 CDNA Australian provide their employed dental practitioners and dental staff with National Guidelines for the Management of Health Care Workers the required materials and equipment to allow these employees Living with Blood-borne Viruses and Healthcare Workers who to fulfil their legal obligations for implementing effective infection Perform Exposure Prone Procedures at Risk of Exposure to prevention and control in their workplace. Blood-borne Viruses (CDNA Guidelines). This requirement applies It is a breach of anti-discrimination laws for dental practitioners irrespective of what local ‘workplace’ guidelines are in place. It to refuse to treat or impose extra conditions on a patient who is also applies to students studying dentistry, dental prosthetics, oral infected with or a carrier of a BBV.4 health therapy, and dental hygiene. If a dental practitioner or student knows or suspects that they have been infected with a BBV, they must consult an appropriately Key compliance points for documentation experienced medical practitioner or infectious disease specialist to Your practice has a comprehensive infection seek appropriate and ongoing medical care, in line with the CDNA prevention and control manual that is updated on a Guidelines. They must follow the advice of their treating medical regular basis, which staff have read and are following. practitioner and any additional stipulations of jurisdictional public In March 2019, the ADA released an Infection Control health authorities. It is not appropriate for a practitioner to rely on Manual template that can be customised to an their own assessment of the risk that they pose to patients. individual dental practice. Diagnosis with a BBV no longer limits the clinical practice of Your staff have access to these ADA Guidelines, the HCWs who perform EPPs. If infected HCWs under treatment 2019 edition of the NHMRC Guidelines, and one of with antiviral medications subsequently meet the criteria for viral the two standards for instrument reprocessing (AS/ suppression or elimination as set out within the CDNA Guidelines, NZS 4815 or AS/NZS 4187). it is possible to return to clinical work undertaking EPPs. Your practice has a vaccination status record and an According to the CDNA Guidelines, with regard to hepatitis B allergy record for each staff member, and both are virus infection, HCWs who are HBV deoxyribonucleic acid (DNA) updated annually. positive are permitted to perform EPPs if they have a viral load below 200 International Units (IU)/mL and meet the other criteria There is a record of workplace injuries. set out in detail within the CDNA Guidelines. Effective antiviral therapy for HBV infection can reduce clinical progression of liver 4. Treating patients with BBV infections disease. Patients with hepatitis B, C, or HIV are treated using standard With regard to hepatitis C virus infection, HCWs must not precautions, and the same cleaning and sterilisation techniques perform EPPs while they are HCV ribonucleic acid (RNA) positive are used for these patients as for other patients. It is important but may be permitted to return to EPPs after successful treatment for dental practitioners and their staff to feel assured that their or following spontaneous clearance of HCV RNA. There are a infection prevention and control procedures are adequate for all number of direct-acting antiviral hepatitis C medications that are patients – whether patients carry BBV infections or not. Patients associated with very high cure rates. should not want to hide their infectious status because of the way HCWs who are HIV positive are permitted to perform EPPs if they the staff act in their presence. have a viral load below 200 copies/mL and meet the criteria set out in detail within the CDNA Guidelines. Early identification of HIV (before the onset of symptoms) will allow the early start of combination antiretroviral therapy (cART) which can reduce the risk of clinical progression, viral transmission, and the morbidity and mortality associated with the condition. 4. Anti-discrimination, privacy, industrial relations and equal opportunity laws apply. Relevant state, territory and commonwealth legislation is listed in the References and Additional Reading. Guidelines for Infection Control | 14 EPPs in dentistry increase the risk of BBV transmission from either The magnitude of the risks is summarised in Table 1 below, which an infected HCW or an infected patient. While performing EPPs, is taken from the 2018 CDNA Guidelines. In general, HCWs are at it is possible that injury to the infected HCW could result in the greater risk of acquiring infections than are dental patients. worker’s blood contaminating the patient’s open tissue, but there The risk of transmission from an infected clinician to a patient is is a very low risk of transmission of a BBV from an infected HCW dependent on a range of factors including the infectivity of the to a patient in Australian health care settings. source clinician (e.g., viral load and effect of viral treatments), the clinical treatment type, and the operator skill and experience. Table 1: Risk of BBV transmission per exposure episode from Effective antiviral drug treatment protocols reduce the infectivity untreated infected HCW to patient and untreated infected patient of individuals. Once zero viral load has been achieved, there to HCW (in the absence of additional risk management). are ongoing requirements, with regular testing for BBVs for the duration of the practitioner’s career, to ensure that virus levels Blood Borne Virus Risk of infected Risk of infected remain undetectable. HCW to patient patient to HCW While the protection of the public’s health is paramount, transmission transmission employers of dental practitioners should also consider, and comply Hepatitis B virus 0.2% - 13.19% 1% - 62%* with, relevant anti-discrimination, privacy, industrial relations, and Hepatitis C virus 0.04% - 4.35% 0% - 7% equal employment opportunity legislation. Employers must ensure Human 0.0000024% - 0.3% the status and rights of infected staff members as employees are immunodeficiency virus 0.0000024% safeguarded. *There is a wide variability in infectiousness of people with hepatitis B reported in the literature and this depends on their hepatitis B e-antigen status. Key compliance points for BBV disease status Source: 2018 CDNA Guidelines. Staff in your practice are aware of the new CDNA Guidelines. Dental practitioners who perform exposure prone procedures undergo testing for antibodies to Hepatitis B, Hepatitis C, and HIV at least once every three years. When a contaminated sharps injury occurs to a staff member, it is followed up correctly with baseline tests of the injured staff member. Guidelines for Infection Control | 15 Section B. Standard precautions for infection prevention and control The following standard precautions form the basis of infection The 5 Moments for Hand Hygiene are: prevention and control and must be carried out routinely for Moment 1: Before touching a patient. all patients. Moment 2: Before a procedure. 1. Hand hygiene Moment 3: After a procedure or body fluid exposure risk. Hand hygiene is a general term applying to processes that aim Moment 4: After touching a patient. to reduce the number of microorganisms on the hands by using Moment 5: After touching a patient’s belongings. either a TGA-approved hand wash or hand rub. The purpose of Note that two moments or opportunities may coincide (i.e., hand hygiene is to prevent transmission of microorganisms from overlap fully). the hands of dental staff to other staff and patients, or from one patient to another patient, either directly or by touching From 1 November 2019, the Australian Commission on Safety contaminated surfaces or objects. Microorganisms that are present and Quality in Health Care (ACQSHC) commenced coordinating on the patient’s skin can be picked up by direct contact (e.g., all aspects of the National Hand Hygiene Initiative (NHHI) for by handshaking). They are also shed into the area immediately Australian health service organisations. For more information on surrounding the patient, depending on factors such as how long the free online educational modules, resources and the HHCApp, the patient is sitting there. These microorganisms can spread if click here. hand hygiene is not performed at all or is inadequate. Hand hygiene must be undertaken before and after contact Hand hygiene involves either: with every patient, and before gloves are put on. It must also be undertaken after removal of gloves, as an essential step before 1. the application of a TGA-approved hand wash or hand rub, the dental practitioner uses their bare hands to write or type up e.g., ABHR, foam, or solution to the surface of the hands; or patient notes. ABHR is used again immediately before gloving 2. the use of a liquid soap solution and water, followed by for the next patient, and if there is any contact made between patting dry with single-use linen or disposable paper towels. the bare hands and contaminated items or contaminated The HHA protocol involves use of an ABHR for all clinical environmental surfaces. situations where hands are visibly clean. The normal routine in a If handshaking occurs, either at the start or end of an dental practice when no oral surgery is being undertaken should appointment, it may increase the risk of transmission of skin- be for dental staff to use ABHR between patient appointments borne pathogens.5 This risk can be mitigated by undertaking and during interruptions within the one appointment. For regular additional hand hygiene after shaking hands. Practitioners should hand hygiene, ABHR is applied onto dry hands and rubbed on for not shake a patient’s hand when greeting them without having 15–20 seconds, after which time the hands will be dry. first completed hand hygiene. For non-surgical dentistry, the advantages of ABHR are that it is How to apply ABHR for regular hand hygiene efficient (taking approximately 15–20 seconds), does not require a sink with running water, detergent, and paper towels, and is When using a hand gel dispenser, apply enough gel for at least much less irritating and drying to the skin than using soap and 20 seconds of rubbing (which is about the same time as singing water (provided an appropriate moisturiser is also used during the the ‘Happy Birthday’ song twice). Follow the instructions for use day). Unlike detergents, ABHRs do not remove skin lipids and they in regard to the quantity of gel to be used (usually 1–2 squirts). do not require paper towel for drying. Ensure that there is sufficient gel to remian on the hands for at least 20 seconds (if there is no gel left on the hands after rubbing When to perform hand hygiene for only 10 seconds, add additional gel). ‘Moments’ or opportunities for hand hygiene are points Only apply gel to dry hands, as water remaining on the hands when there is a perceived or actual risk of pathogen transmission after handwashing dilutes the product, thus decreasing its from one surface to another via the staff member’s hands. effectiveness. Further information on hand decontamination with ABHR, and posters on ‘How to Hand Rub’ can be downloaded here. 5. http://apps.who.int/iris/bitstream/10665/78060/1/9789241503372_eng.pdf and http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. Guidelines for Infection Control | 16 How to select an appropriate ABHR product Location of hand gel dispensers When selecting an ABHR product, ensure that the product meets Keep hand gel dispensers away from children to prevent the EN1500 testing standard for bactericidal effect and that the accidental ingestion of gel. product has been approved by the TGA for use as a hand hygiene Avoid having hand gel dispensers located at handwashing sinks – product for a healthcare setting. A range of ABHR products are as this might cause confusion for staff who think that they should registered with the TGA and are listed on the Australian Register do both handwashing and ABHR application (in fact, only one is of Therapeutic Goods (ARTG). This listing will normally be needed). Washing hands with soap and water immediately before indicated on the product label, and cost should never dictate the or after using an ABHR is not only unnecessary but may lead to use of a non-compliant product. Approved products include gels, occupational irritant dermatitis. For this reason, there is no need liquids (solutions), and foams. to position ABHR dispensers near the handwashing sink. It is both For staff whose selection and use of an ABHR product may be desirable and convenient to position ABHR dispensers close to influenced by religious factors, it is important to know that using the clinical working area, provided their location is not prone to hand gel does not result in any significant alcohol absorption splashing from patient fluids. through the skin, and thus, using hand gel in the clinic does not Keep bulk supplies of hand gel well away from any sources of breach a prohibition around alcohol (ethanol) consumption. The high temperature or ignition, such as open flames. All ABHR issue can be avoided by choosing an isopropanol-only hand gel products are flammable, with flashpoints ranging from 21 °C product that has no ethanol at all. to 24 °C, depending on the type and concentration of alcohol Choose an ABHR product that suits the skin type of the staff. present. The maximum total quantity of all flammable liquids When the correct product is chosen, the emollient agent(s) in the allowed for ‘minor storage’ is no more than 10 litres per 50 gel will prevent the skin from becoming dry or irritated and should square metres of floor space (as per AS 1940:2004 The Storage not leave a sticky residue on the hands. A poorly chosen ABHR and Handling of Flammable and Combustible Liquids, Section 2, product that has poor acceptance is unlikely to be used. Staff with Table 2.1). an existing skin irritation or skin disease may experience a stinging Bottles of ABHR should not be ‘topped up’ because the outside of sensation when first using ABHR. Usually, this subsides over the dispenser may become contaminated. Never tip or pour hand several weeks with the ongoing use of an emollient-containing gel from one bottle to another, as this may cause contamination ABHR. However, medical advice should be sought if symptoms of the second bottle and its contents. Empty bottles of hand gel persist. are to be discarded and not reused. There are specific high potency ABHRs designed for surgical Use of moisturiser hand decontamination, which may be used as a substitute for antimicrobial soaps in a surgical scrub. Such products are ABHR can be used as often as is required. However, a compatible specifically labelled as being for surgical hand preparation. They water-based moisturiser should be applied, as required, up to four are formulated in a different way to those marketed for regular times per day. hand hygiene. They have higher concentrations of ethanol and/ When is handwashing needed, rather than ABHR? or isopropanol and are tested using a more stringent performance Hands must always be washed under the following situations: test. Such products require a prolonged rubbing time (typically 1. at the start of a working session; 90 seconds) to achieve surgical hand hygiene. When using such products, be aware that the extended rubbing time requires use 2. at the end of a session, when leaving for a meal or other of a clock to ensure that the exposure time is sufficiently long to break, or at the end of the day; achieve surgical hand decontamination. These products require a 3. after toilet breaks; and multi-step process or multiple applications to achieve the required 4. whenever they are visibly dirty, contaminated with level of skin preparation. Following the product instructions is proteinaceous material, or visibly soiled with blood or other critical for their proper use and storage. Note that high potency body fluids. ABHRs designed for surgical hand decontamination are flammable Washing hands with liquid soap and water is preferred in each of at room temperature and these must be stored away from these situations due to the mechanical removal effect. sources of ignition (such as gas burner flames, electrosurgery or Further information on hand washing, and posters on ‘How to diathermy). Handwash’ can be downloaded here. Guidelines for Infection Control | 17 Handwashing should be undertaken in dedicated sinks located and poor quality paper towel that abrades the skin. Other factors in the clean zone. These sinks should preferably be fitted with that may contribute to dermatitis include the fragrances and non-touch taps (e.g., operated by elbow controls or by sensors); preservatives found in domestic hand care products (which can otherwise, handwashing should be carried out using a non-touch cause contact allergies), donning gloves while hands are still wet, technique. If conventional (hand-operated) taps are used, they use of hot water for handwashing, and failing to use appropriate should be operated with the use of a paper towel, rather than moisturisers. with bare hands. Handwashing must not be undertaken using the Lacerated, chafed, or cracked skin can allow entry of sink in the contaminated zone that is used for cleaning or rinsing microorganisms. Any cuts or open wounds need to be covered instruments. with a flexible, fluid-proof/waterproof dressing. Handwashing, rather than ABHR, is required when dental practitioners work outside the normal clinical environment, e.g., Appropriate preparation of the hands and wrists – in a nursing home or at a patient’s home, since ABHR products do ‘bare below the elbows’ not reliably inactivate norovirus, rotavirus, hepatitis A, and certain A dental practice needs a clear policy within their infection other enteric viruses which spread readily from contact with prevention and control manual regarding the ‘bare below the contaminated surfaces. elbows’ principle. In line with the National Hand Hygiene Initiative, Do not put hand gel dispensers in the toilet area. Alcohols have all hand, wrist, or nail jewellery (e.g., all rings (including rings with limited activity against non-enveloped (non-lipophilic) viruses such smooth surfaces and rings with stones), bangles and bracelets), as those linked to highly contagious gastrointestinal infections watches, and wearable devices such as ‘Fitbits’, must be removed including rotavirus, norovirus, and hepatitis A. Toilets need proper by clinical staff prior to putting on gloves, as their presence handwashing facilities, and a suitable means for drying the hands, impairs correct handwashing, compromises the fit and integrity of such as paper towel. Some practices use hot air dryers as an gloves, and promotes the growth of skin microorganisms. Areas alternative. These tend to spread microorganisms from the skin of skin beneath rings on the fingers become much more heavily into the environment much more than paper towels, with the colonised with microorganisms than adjacent areas, and wearing worst being jet air dryers. rings increases the carriage rate of Gram-negative bacteria on the hands of clinical staff. This is why rings should be removed. Each dental practice needs a clear policy statement within its infection prevention and control manual regarding the need for clinical staff to keep their nails both short and natural. Wearing nail polish, artificial fingernails, or fingernail extenders is not permitted, as these cause larger amounts of microorganisms to be retained on the hands, particularly around the nail beds, despite handwashing. Keeping nails short also prevents them from puncturing gloves and makes hand hygiene easier to perform. The ‘bare below the elbows’ approach also includes avoiding wearing cloth coats or linen gowns with long sleeves during a non-surgical working day. Long sleeves on clothing that is worn over a clinical session will become contaminated with microorganisms from the working environment, and from patients, and may impede proper handwashing. When a long- sleeved gown or coat is used (for example, during surgical procedures such as implants), this should be removed after the procedure and prior to seeing the next patient. Hand care Hands must be well cared for because intact skin is a first- line defence mechanism against infection. Damaged skin can Key compliance points for ‘bare below the elbows’ lead to infection in the host and can harbour higher numbers Check that gowns, coats and undershirts worn by of microorganisms than intact skin, increasing the risk of clinical staff have short sleeves. transmission to others. Damaged skin in dental practitioners Ensure that fingers, hands, and wrists are free of items and clinical support staff is an important issue because of the that retain micro-organisms or hinder hand hygiene. high frequency of dry, itchy skin among these staff from irritant contact dermatitis. It is caused most often by frequent and Ensure that nails are kept short and natural, without repeated use of handwashing products (especially liquid soap), coatings. Guidelines for Infection Control | 18 2. Personal protective equipment (PPE) as soon as they are cut, torn, or punctured. Gloves must be removed, and hand hygiene undertaken, before accessing items in Wearing personal protective clothing and equipment where drawers or touching areas in the clean zone. splashes and aerosols are likely to be generated is an important way to reduce the risk of transmission of infectious agents. Dental Gloves must be removed as soon as clinical treatment is complete, practitioners and clinical support staff must be provided with all and then hand hygiene must be undertaken immediately to appropriate necessary protective clothing and equipment for the prevent the transfer of microorganisms to other patients or procedure being undertaken, and need to be educated on the environmental surfaces. Gloves that are contaminated with correct use of these items. bacteria arising from biofilms have been shown to re-contaminate surfaces for up to 19 subsequent touches.6 Barrier protection of the body, including gloves, mask, eyewear, and an outer layer of protective clothing (such as a clinical gown Glove selection or other dedicated outer clothing), must be removed before To protect the skin of the wearer, the glove must cover the hand leaving the work area (e.g., dental surgery, instrument processing and wrist region. As dental clinic