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FAQ's Disinfection

Frequently Asked Questions (FAQs) on Dental Infection Control



Top|Instruments & Equipment|Disinfection


Frequently Asked Questions for Disinfection

Q Should a specific, well-defined area be designated for instrument processing?

Q What is the appropriate disinfection technique for impressions?

Q Is it okay to use dishwashing detergent, rather than an enzymatic solution, in an ultrasonic cleaner?

Q Is a thermal washer/disinfector an acceptable substitute for ultrasonic cleaning of dental instruments?

Q Can disposable items be disinfected and reused?

Q How do you address the fact that many disinfectants need 10 minutes or more to work and the average time they stay on is 1-3 minutes?

Q How do we disinfect laptops in the treatment room?

Q What is the best way to disinfect utility gloves?

Q The instructions for the electrosurgery tips my practices uses say to "cold sterilize” them. What cold sterilization methods does the Food and Drug Administration (FDA) approve for use?

Q What classification is alcohol in terms of its ability to disinfect: high level, intermediate level, or low level? Does ethyl alcohol kill TB? If soap is added to ethyl alcohol, will it become a more effective disinfectant? Is ethyl alcohol a sufficient disinfectant for dental office surfaces such as countertops, cupboards?

Q I read recently that placing disinfectant in a container with 4X4 gauze for use on dental equipment is not recommended. Can you explain why this should not be done?

Q What type of disinfectant is best for use on dental patient chairs?

Q Is it acceptable to use bleach as a precleaner for surfaces followed by glutaraldehyde for surface disinfection?

Q What surface disinfectants are strong enough to be effective yet gentle enough to prevent damage to dental equipment?

Q Can OSAP recommend a non-corrosive alternative to glutaraldehyde for use in reprocessing impression trays?

Q How should we disinfect surfaces that have been touched or contaminated with blood or other potentially infectious materials?

Q What is the better choice for controlling surface contamination: barriers or between-patient disinfection?

Q I was asked how long microorganisms live on surfaces (i.e. when chart paperwork is contaminated). Does OSAP have an answer, or how can I find one?

Q Which technique is recommended: spray, wipe, spray or wipe, discard, wipe.

Q We recently heard that there have been some changes in disinfection guidelines for the dental office. Can you send us the guidelines on spray-wipe-spray –vs.- plastic barriers and which areas in the operatory should have what? We are concerned about mirror handles, air/water syringes, suction, etc.


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Q Should a specific, well-defined area be designated for instrument processing?

A If possible, instruments should be cleaned and sterilized in an area designated for that purpose. If a lack of space prohibits this scenario, establish a clearly defined location for holding and processing contaminated instruments and devices. Ensure that this area is physically separated from the area where clean instruments are stored. If instruments must be decontaminated in patient treatment areas, don't seat the next patient until all instrument processing has been completed and the area has been cleaned and disinfected.

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Q What is the appropriate disinfection technique for impressions?

A Cleaning and disinfecting impressions before pouring in stone is an important aspect of laboratory asepsis. Different materials require different handling techniques. In general, impressions should be gently scrubbed with a camel hair brush (i.e., artists brush, one-half inch bristle) and a liquid detergent to remove bioburden. Scrubbing gently with dental stone sprinkled into the impression will remove stubborn materials. Always consult the impression material manufacturer or instructions for use for advice on using compatible disinfectants. Hydrocolloid and polyether impression materials generally are sprayed to saturate for the required time with an intermediate level disinfectant and placed in a plastic bag or sealed container to prevent evaporation of the agent. More stable silicone (vinyl polysiloxane) or rubber-based impression material typically may be immersed for disinfection(1).

References:
(1) OSAP. OSAP Position Paper: Laboratory Asepsis. November 1998.

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Q Is it okay to use dishwashing detergent, rather than an enzymatic solution, in an ultrasonic cleaner?

A To ensure maximum ultrasonic cleaning action and to avoid problems with the equipment, use a quality detergent specifically formulated for and recommended by the manufacturer of your machine. Using products not intended for ultrasonic machines may cause pitting or other harm to the unit.

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Q Is a thermal washer/disinfector an acceptable substitute for ultrasonic cleaning of dental instruments?

A Yes. Washer/disinfectors and washer/decontaminators that have been cleared for marketing by the Food and Drug Administration (FDA) are a suitable alternative to ultrasonic cleaning. Household dishwashers, however, are not acceptable for healthcare applications. Dishwashers and other household appliances have not been evaluated by the FDA to guarantee adherence to the strict operating parameters that healthcare applications demand.

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Q Can disposable items be disinfected and reused?

A If the item is intended as single use, it should be used on one patient and then discarded. If a disposable item is intended for more than one use, it must be reprocessed under the same guidelines as those used for any other critical, semicritical, or noncritical item, depending upon its characteristics and intended use. Always follow the product manufacturer's instructions with regard to reuse life and reprocessing of disposable items.

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Q How do you address the fact that many disinfectants need 10 minutes or more to work and the average time they stay on is 1-3 minutes?

A The person responsible for disinfecting surfaces between patients should perform this task in a way that allows the full contact time to be achieved. Adherence to the manufacturers instructions is important to ensure that the product works as intended(1). Often, this merely requires some rearranging of the order of the steps involved. The areas requiring disinfection should be cleaned and then saturated with enough disinfectant to remain for the required contact time without evaporation. If this is done as soon as the patient leaves the treatment room, the instruments may be removed, barriers changed, new instruments brought in, and treatment room prepared for the next patient. By the time the next patient is brought in, seated, and the dental procedure undertaken, chances are time required for disinfection has elapsed.

References:
(1) OSAP. Chemical Agents for Surface Disinfection Reference Chart. October 1998. Available at http://www.osap.org/issues

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Q How do we disinfect laptops in the treatment room?

A Since the use of liquid chemical germicides could prove harmful to laptop computers, the proper management would be to prevent contamination from occurring. Use impervious barriers or plastic shields, or place the computer in a location that is not subject to contamination via touch or splatter.

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Q What is the best way to disinfect utility gloves?

A Utility gloves, referred to as heavy-duty gloves by OSHA, must be disinfected according to the glove manufacturer's directions. To prevent contamination of bare hands, remove heavy-duty gloves in a manner that does not require barehanded contact with outer surfaces of the gloves prior to decontamination.

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Q The instructions for the electrosurgery tips my practices uses say to "cold sterilize” them. What cold sterilization methods does the Food and Drug Administration (FDA) approve for use?

A "Cold sterilization” entails the use of chemicals that FDA classifies as high-level disinfectants/sterilants. Chemicals in this category are required to have FDA clearance for their claims.

Ideally, all items that enter the patient's mouth and come into contact with oral tissues should be heat sterilized. If this is not feasible because the device or instrument cannot withstand the heat sterilization process, a high-level disinfectant should be used.

The FDA maintains a list of products that have received clearance as chemical sterilants.(1) The list includes information regarding proper contact time, active ingredients and reuse or shelf life. Always read instructions carefully before using a chemical germicide.

References:
1) Food and Drug Administration. FDA-cleared sterilants and high level disinfectants with general claims for processing reusable medical and dental devices. Available at http://www.fda.gov/cdrh/ode/germlab.html

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Q What classification is alcohol in terms of its ability to disinfect: high level, intermediate level, or low level? Does ethyl alcohol kill TB? If soap is added to ethyl alcohol, will it become a more effective disinfectant? Is ethyl alcohol a sufficient disinfectant for dental office surfaces such as countertops, cupboards?

A Ethanol in concentrations of 70% and higher is considered an intermediate-level disinfectant and is considered broadly virucidal and tuberculocidal. The virucidal activity of isopropanol is limited primarily to lipid-containing viruses.

Ethanol is tuberculocidal. Adding ethanol to a disinfectant formula can shorten the required contact time for inactivation of benchmark organism Mycobacterium tuberculosis but may have no effect on contact time for other organisms.

Because alcohols are poor cleaners and evaporate rapidly, they may not be the best choice for use on environmental surfaces(1). Adding soap to alcohol may improve its usefulness as a cleaner but will not increase its germicidal efficacy.

References:
1) Ali Y, Dolan MJ, Fendler EJ, Larson EL. In Block SS., ed. Disinfection, Sterilization, and Preservation, 5th edition. Philadelphia: Lippincott Williams and Wilkins, 2001

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Q I read recently that placing disinfectant in a container with 4X4 gauze for use on dental equipment is not recommended. Can you explain why this should not be done?

A In general, cotton fibers contained in gauze may shorten the effectiveness of some disinfecting agents when stored in containers together.

Germicides, especially iodophors or chlorines, may be inactivated or absorbed by the gauze. As such, disinfectants should not be stored in containers with gauze.

If used to apply disinfectant to surfaces, gauze should be saturated with the disinfecting agent at the time of use. Although this is an acceptable option, disposable paper towels typically are a more economical alternative.

Always wear appropriate personal protective equipment when handling chemicals and managing contaminated surfaces.

References:
1) Molinari JA. In Cottone JA, Terezhalmy GT, Molinari JA, eds. Practical Infection Control In Dentistry, 2nd. edition. Philadelphia: Williams & Wilkins, 1996:195.

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Q What type of disinfectant is best for use on dental patient chairs?

A Contact the manufacturer of the dental chair for specific recommendations. Because new chairs should still be under warranty, you should follow the manufacturer's advice and directions/instructions. It's a good idea to ask the manufacturer to send you the written instructions for your records.

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Q Is it acceptable to use bleach as a precleaner for surfaces followed by glutaraldehyde for surface disinfection?

A Some sodium hypochlorite (bleach) formulations are suitable surface disinfectants. It is important to ensure that the chemical will not damage the materials on the equipment and surfaces being disinfected. Because bleach is effective for removal of blood or other organic soils, it may be used as both a cleaner and disinfectant.

Glutaraldehyde is a high-level disinfectant/sterilant that is highly irritating to the skin, mucous membranes, and respiratory system. It is a high-level instrument-immersion disinfectant and should never be used in an attempt to disinfect surfaces. Its vapors have been associated with cases of occupational asthma, and the Food and Drug Administration (FDA) requires the all glutaraldehyde labels warn that the product should not be used outside a closed container.

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Q What surface disinfectants are strong enough to be effective yet gentle enough to prevent damage to dental equipment?

A Because of the large number of different disinfectant formulations and the many different materials used to manufacture dental equipment, OSAP suggests you contact the dental equipment manufacturer to obtain recommendations for compatible disinfecting agent(s).

Using impervious barriers on surfaces that are likely to be touched during dental procedures can reduce the need for chemical disinfectants and prolong the life of equipment.

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Q Can OSAP recommend a non-corrosive alternative to glutaraldehyde for use in reprocessing impression trays?

A Metal impression trays are heat-stable and therefore should be thoroughly cleaned and heat-sterilized after each use.

Plastic impression trays are intended for single-use and should be discarded when laboratory procedures are completed.

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Q How should we disinfect surfaces that have been touched or contaminated with blood or other potentially infectious materials?

A The Centers for Disease Control and Prevention (CDC) states, "A chemical germicide registered with the EPA as a ‘hospital disinfectant' and labeled for tuberculocidal (i.e., mycobactericidal) activity is recommended for disinfecting surfaces that have been soiled with patient material."

As an alternative to between-patient disinfection, many practices choose to use impermeable barriers to cover and protect surfaces that would otherwise become contaminated (through touch or with droplet spatter). The barriers are simply removed, discarded, and replaced after each patient.

The CDC will publish revised infection control guidelines for dentistry in the near future. Whether this specific recommendation will change is unknown at this time. Check the CDC Div. of Oral Health website for updates on the new guidelines.

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Q What is the better choice for controlling surface contamination: barriers or between-patient disinfection?

A  As an alternative to between-patient disinfection, environmental surfaces may be covered and protected with fluid-resistant, disposable barriers that are removed, discarded, and replaced after each patient visit.

Whether a practice uses protective barriers or surface disinfection is a personal choice, but many experts advocate the use of surface barriers, especially for surfaces that are difficult to clean (for example, light handles and control panels). Barriers also are the more time-saving option. If barriers are not used, exposed environmental surfaces that are contaminated with blood or saliva (through contact or spatter) must be first cleaned and then disinfected after every patient. If the barriers remain intact, surface cleaning and disinfection need only be performed at the end of each clinic day. If a barrier becomes compromised during patient care, however, the surface beneath it must be cleaned and disinfected before a clean barrier is placed.

Most dental practices utilize a combination of barriers and between-patient cleaning and disinfection to maintain operatory asepsis and minimize the potential for cross-contamination.

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Q I was asked how long microorganisms live on surfaces (i.e. when chart paperwork is contaminated). Does OSAP have an answer, or how can I find one?

A Each pathogen (e.g. bacteria, viruses, etc.) has a different survival time period and without culturing each record, it would be impossible to know what specific pathogens are present on the charts or other inanimate surfaces/objects.


For example, the authors of Infection Control & Management of Hazardous Materials for the Dental Team state that the Hepatitis B virus can remain viable at room temperature for at least one month. (1)

If notations must be made in the patient record/chart during treatment dental infection control experts still recommend using over-gloves or using scrap paper to make notations that can be transferred to the patient chart after treatment is completed.

Dental infection control experts state the following:

Cross-contamination often occurs without anyone noticing. During treatment, you may reach for an instrument that is stored in a cabinet, make notes in the patient's record, answer the phone, or adjust your glasses. These events, and others can cause the potential transfer of microorganisms.

There are two ways to reduce cross-contamination: (1) Don't interrupt treatment, (2) Don't touch anything that is not essential for patient treatment. During treatment, avoid touching unprotected surfaces and equipment, including the patient's record. While you may need to make chart entries while in the operatory, the patient's record poses a unique challenge because it's very difficult to decontaminate. Ideally, records should be left outside the treatment area, with notes made after treatment is completed. If the record must be kept in the operatory, it should be stored in a place not at risk for cross-contamination, such as in a clean drawer or located on a counter out of the area of aerosolization. If you must make notes, use an over-glove. If you are using a computer system, the keyboard in the operatory should be barrier protected between patients. In either case, you can write on a separate scrap piece of paper and later rewrite those notes in the chart outside the operatory. It may also be easier to have another person make entries, provided their hands, or gloves, are not contaminated. Remember to barrier protect or clean/disinfect the pen or pencil between patients, and discard any scrap paper in the same manner as contaminated or plain waste, as appropriate.(2)

Resources:

(1) Infection Control & Management of Hazardous Materials for the Dental Team, 3rd edition. By Miller and Palenik. Elsevier/Mosby Publisher. Copyright 2005.

(2) OSAP's Interact Infection Control & Safety Training System by Eklund and Bednarsh. Copyright 1999, InVision, Inc..

There are several studies that may be of interest to you.

1) Fomites and Infection Transmission by Kris Ellis. http://www.infectioncontroltoday.com/articles/6b1feat2.html#

2) Survival of Enterococci and Staphylococci on Hospital Fabrics and Plastic by Alice Neely and matthew Maley. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=86187

3) Survival of Acinetobacter baumannii on Dry Surfaces by Constanze Wendt, Beate Dietze, Ekkehart Dietz, and Henning Ruden. Journal of clinical Microbiology, June 1997, p. 1394-1397. Vol. 35, No. 6.

4) The Survival Rates of Streptococci In The Dark by Leon Buchbinder and Earle Phelps.

http://www.jb.asm.org

5) Survival of herpes simplex virus and other selected microorganisms on patient charts: potential source of infection by L.Thomas, R. Sydiskis, D. DeVore, and G Krywolap.

JADA. J Am Dent Assoc, Vol 111, No. 3, 461-464.

http://www.jada.ada.org/cgi/content/abstract/111/3/461?ck=nck

6) Using A biological Indicator To Detect Potential Sources Of Cross-Contamination In The Dental Operatory by Raymond Hackney Jr., James Crawford, and Jerry Tulis.

JADA. Vol. 129, Nov. 1998.

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Q Which technique is recommended: spray, wipe, spray or wipe, discard, wipe.

A OSAP is not currently aware of any federal regulations that prohibit the use of the spray-wipe-spray technique. However, individual states, through state legislation or State Board Of Dental Examiners/Licensing Boards, could prohibit the use of disinfecting sprays.

OSAP is not in a position to maintain individual state laws/regulations, therefore, you should contact your State Board directly.

OSAP provides links to state agencies that may be viewed at:

http://www.osap.org/displaycommon.cfm?an=1&subarticlenbr=71

OSAP can provide you with the following general information concerning both techniques.

The Authors of OSAP's From Policy to Practice: OSAP's Guide to the Guidelines. offer the following information:

For pre-cleaning clinical surfaces:

Use a low to intermediate-level disinfectant and the "spray-wipe-spray” technique to clean and disinfect clinical contact surfaces. First clean, then disinfect. Spray the surface to be cleaned with a cleaner or cleaner/disinfectant. Then, wipe vigorously using paper towels. Once cleaned, spray the surface again, this time with a disinfectant. Cover the entire surface, and allow the disinfectant to remain undisturbed on the surface for the contact time indicated on its label. (1)

The authors also offer the following alternative to pre-cleaning clinical surfaces:

Wipe a pre-moistened cleaner-disinfectant towelette over the surface to be cleaned. Check the label to be sure that the wipe is a cleaner (some disinfectant wipes may require a separate cleaner). Carefully follow label instructions. Some wipes may be effective only on a limited surface area (approximately 3 sq. ft.). (1)

After cleaning, disinfect the surface:

Spray the disinfectant over the entire surface, using towels to reduce overspray. Let the surface remain moist for the contact time stated on the disinfectant's label. Wipe the surface dry if it is still wet when ready for patient care. (1)

The authors also offer the following alternative to spraying disinfectants on clinical surfaces:

Saturate the surface using a pre-moistened disinfectant towelette (wipe). Let the surface remain moist for the contact time stated on the disinfectant's label. Wipe the surface dry if it is still wet when ready for patient care. (1)

Resource:

(1) From Policy to Practice: OSAP's Guide to the Guidelines. Copyright 2004 by OSAP.

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Q We recently heard that there have been some changes in disinfection guidelines for the dental office. Can you send us the guidelines on spray-wipe-spray –vs.- plastic barriers and which areas in the operatory should have what? We are concerned about mirror handles, air/water syringes, suction, etc.

A We believe you are referring to the Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental Healthcare Settings. The CDC revised and updated the guidelines in December 2003. However, there may also be state/local regulations that OSAP would not be aware of. Therefore, you should also check with your State Board of Dental Examiners/Licensing Board for all applicable infection control requirements in your state.

OSAP would like to refer you directly to the guidelines. In part, they state the following:

Clinical contact surfaces can be directly contaminated from patient materials either by direct spray or spatter generated during dental procedures or by contact with DHCP's gloved hands. These surfaces can subsequently contaminate other instruments, devices, hands, or gloves. Examples of such surfaces include (1):

light handles,
switches,
dental radiograph equipment,
dental chairside computers,
reusable containers of dental materials,
drawer handles,
faucet handles,
countertops,
pens,
telephones, and
doorknobs.
Barrier protection of surfaces and equipment can prevent contamination of clinical contact surfaces, but is particularly effective for those that are difficult to clean. Barriers include clear plastic wrap, bags, sheets, tubing, and plastic-backed paper or other materials impervious to moisture. Because such coverings can become contaminated, they should be removed and discarded between patients, while DHCP are still gloved. After removing the barrier, examine the surface to make sure it did not become soiled inadvertently. The surface needs to be cleaned and disinfected only if contamination is evident. Otherwise, after removing gloves and performing hand hygiene, DHCP should place clean barriers on these surfaces before the next patient. (1)

If barriers are not used, surfaces should be cleaned and disinfected between patients by using an EPA-registered hospital disinfectant with an HIV, HBV claim (i.e., low-level disinfectant) or a tuberculocidal claim (i.e., intermediate-level disinfectant). Intermediate-level disinfectant should be used when the surface is visibly contaminated with blood or OPIM. Also, general cleaning and disinfection are recommended for clinical contact surfaces, dental unit surfaces, and countertops at the end of daily work activities and are required if surfaces have become contaminated since their last cleaning. To facilitate daily cleaning, treatment areas should be kept free of unnecessary equipment and supplies. (1)

Manufacturers of dental devices and equipment should provide information regarding material compatibility with liquid chemical germicides, whether equipment can be safely immersed for cleaning, and how it should be decontaminated if servicing is required. Because of the risks associated with exposure to chemical disinfectants and contaminated surfaces, DHCP who perform environmental cleaning and disinfection should wear gloves and other PPE to prevent occupational exposure to infectious agents and hazardous chemicals. Chemical- and puncture-resistant utility gloves offer more protection than patient examination gloves when using hazardous chemicals. (1)

In addition, most dental practices utilize a combination of barriers and between-patient cleaning and disinfection to maintain operatory asepsis and minimize the potential for cross-contamination.

The use of protective barriers generally eliminates the need for surface disinfection during operatory turn-around. However, surfaces must be cleaned and disinfected anytime the barrier has been compromised as well as at the beginning and end of each clinic day.

Environmental surface disinfectants are supplied as concentrates, premixed solutions, sprays, foams, impregnated wipes, and tablets. Pump-sprays, however, are considered the best vehicle for delivering cleaning/disinfecting agents to contaminated surfaces.

The pump concentrates spray liquid on the surface rather than aerosolizing it, which allows the chemical to penetrate into crevices. In addition, spray bottles eliminate potential inactivation or absorption of the disinfectant by gauze, paper, or sponge applicators. (2) (3) (4)

According to dental infection control expert, Dr. Charles Palenik, disinfection is now called environmental infection control. The emphasis has gone away from the primary use of chemicals to one that uses mostly surface covers. In fact, areas that need attention (disinfection or covering) are now called clinical contact surfaces. (5)

The Authors of OSAP's From Policy to Practice: OSAP's Guide to the Guidelines. Copyright 2004, offer the following information:

For pre-cleaning clinical surfaces:

Use a low to intermediate-level disinfectant and the "spray-wipe-spray” technique to clean and disinfect clinical contact surfaces. First clean, then disinfect. Spray the surface to be cleaned with a cleaner or cleaner/disinfectant. Then, wipe vigorously using paper towels. Once cleaned, spray the surface again, this time with a disinfectant. Cover the entire surface, and allow the disinfectant to remain undisturbed on the surface for the contact time indicated on its label. (6)

The authors also offer the following alternative to pre-cleaning clinical surfaces:

Wipe a pre-moistened cleaner-disinfectant towelette over the surface to be cleaned. Check the label to be sure that the wipe is a cleaner (some disinfectant wipes may require a separate cleaner). Carefully follow label instructions. Some wipes may be effective only on a limited surface area (approximately 3 sq. ft.). (6)

After cleaning, disinfect the surface:

Spray the disinfectant over the entire surface, using towels or reduce overspray. Let the surface remain moist for the contact time stated on the disinfectant's label. Wipe the surface dry if it is still wet when ready for patient care. (6)

The authors also offer the following alternative to spraying disinfectants on clinical surfaces:

Saturate the surface using a pre-moistened disinfectant towelette (wipe). Let the surface remain moist for the contact time stated on the disinfectant's label. Wipe the surface dry if it is still wet when ready for patient care. (6)

Resource:

1) Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental
Healthcare Settings.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

2) Infection Control and Management of Hazardous Materials for the Dental Team by
Miller and Palenik. Mosby, 2005.

3) OSAP's Infection Control In Practice: Demystifying Disinfectants, August 2002 and OSAP's
Monthly Focus # 6, 1998

4) Practical Infection Control In Dentistry, 2nd. Ed. By Cottone, Terezhalmy, Molinari. Publisher,
Williams & Wilkins, 1996.

 

5 Dr. Charles Palenik, MS, PhD. Assistant Director of Infection Control Research and Services.
Indiana University School of Dentistry.

6. From Policy to Practice: OSAP's Guide to the Guidelines. Copyright 2004 by OSAP.


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