| FAQ - Disinfection - 2013
Are dental offices legally required to use a tuberculocidal disinfectant for clinical contact surfaces, or is a hospital grade low-level disinfectant sufficient?
The 2003 CDC guidelines for infection control in dentistry states as follows:
Environmental Infection Control
In the dental operatory, environmental surfaces (i.e., a surface or equipment that does not contact patients directly) can become contaminated during patient care. Certain surfaces, especially ones touched frequently (e.g., light handles, unit switches, and drawer knobs) can serve as reservoirs of microbial contamination, although they have not been associated directly with transmission of infection to either DHCP or patients. Transfer of microorganisms from contaminated environmental surfaces to patients occurs primarily through DHCP hand contact (286,287). When these surfaces are touched, microbial agents can be transferred to instruments, other environmental surfaces, or to the nose, mouth, or eyes of workers or patients. Although hand hygiene is key to minimizing this transferal, barrier protection or cleaning and disinfecting of environmental surfaces also protects against health-care–associated infections.
Environmental surfaces can be divided into clinical contact surfaces and housekeeping surfaces (249). Because housekeeping surfaces (e.g., floors, walls, and sinks) have limited risk of disease transmission, they can be decontaminated with less rigorous methods than those used on dental patient-care items and clinical contact surfaces (244). Strategies for cleaning and disinfecting surfaces in patient-care areas should consider the 1) potential for direct patient contact; 2) degree and frequency of hand contact; and 3) potential contamination of the surface with body substances or environmental sources of microorganisms (e.g., soil, dust, or water).
Cleaning is the necessary first step of any disinfection process. Cleaning is a form of decontamination that renders the environmental surface safe by removing organic matter, salts, and visible soils, all of which interfere with microbial inactivation.
The physical action of scrubbing with detergents and surfactants and rinsing with water removes substantial numbers of microorganisms. If a surface is not cleaned first, the success of the disinfection process can be compromised. Removal of all visible blood and inorganic and organic matter can be as critical as the germicidal activity of the disinfecting agent (249). When a surface cannot be cleaned adequately, it should be protected with barriers (2).
Clinical Contact Surfaces
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
• light handles,
• dental radiograph equipment,
• dental chairside computers,
• reusable containers of dental materials,
• drawer handles,
• faucet handles,
• telephones, and
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 (260,288).
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 (1,2,288).
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
(2,244). 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
(13). To facilitate daily cleaning, treatment areas should be kept free of unnecessary equipment and supplies.
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 (289). 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
It should be noted that many US states have adopted the 2003 CDC guidelines for infection control in dentistry as part of their regulatory code. Since regulations may vary by state, it is recommended that you contact your state dental board/dental licensing agency and state public health agency (i.e., State Health Dept) for further information on this question and the legal requirements in your state. OSAP is not aware of all the regulations at the individual state level. Disinfectant products should always be used in strict accordance with manufacturer’s directions. Product-specific questions should be directed to the manufacturer.
Additionally, Infection Control and Hazardous Materials for the Dental Team provides step-by step procedural information as follows:
Precleaning and Disinfecting Surfaces
Goal: To clean and disinfect contaminated surfaces and equipment
Liquid cleaner/disinfectant or disinfectant towelettes
Paper towels or gauze pads
Material safety data sheet for cleaner/disinfectant
Gloves, mask, clothing, and eye protection
1. Put on utility gloves, mask, protective eyewear, and protective clothing.
Rationale: Protective gear prevents contact with contaminants and chemicals through touching or splashing
2. Choose a cleaner/disinfectant that is compatible with the surfaces to be cleaned and disinfected. Many manufacturers of dental equipment have determined which surface disinfectants are most appropriate for their products (e.g., dental chairs and unit accessories) from a material compatibility point of view.
Rationale: One wants to cause the least damage possible to the surfaces being decontaminated.
3. Confirm that the precleaning/disinfecting product(s) have been prepared correctly (if diluted) and are fresh (if necessary). Read and follow the product label directions.
Rationale: Using the product as directed helps ensure that the product works effectively.
4. For spray-wipe-spray: Spray the surface with the cleaning/disinfecting agent and vigorously wipe with paper towels. Holding paper towels behind appropriate surfaces during the procedure will reduce overspray. Alternatively, saturate a paper towel or gauze pad with the cleaning/disinfecting agent and vigorously wipe the surface. Use a brush for surfaces that do not become visibly clean from wiping and consider covering them with a plastic barrier in the future. If cleaning large areas or multiple surfaces or large spills, use several towels or pads for cleaning as not to transfer contamination to other surfaces. Disinfect the precleaned surface by respraying the disinfecting agent over the entire surface using towels to reduce overspray (or apply with a saturated pad). Let the surface remain moist for the longest contact time indicated on the product label (usually 10 minutes). Vertical surfaces may dry more quickly.
5. For wipe-discard-wipe: Obtain a disinfectant towelette from its container, close the container lid, and vigorously wipe (clean) the surface. Discard the towelette, obtain a fresh towelette, and wipe the surface again for disinfection. Discard the towelette and let the surface dry.
Rationale: Proper precleaning (predisinfection) is essential to reduce the level of bioburden so the disinfecting step will have the best chance to kill remaining microbes. Using a disinfectant/cleaner begins to kill microbes on the surface during the cleaning step and helps protect the person doing the cleaning. Although the precleaning step removes/kills some microbes, the subsequent disinfectant step helps ensure removal, death of the contaminants.
6. If the surface is still wet when ready for patient care, wipe dry. If the surface will come into direct contact with the patient’s skin or mouth, rinse/wipe off residual disinfectant with water.
Rationale: This prevents the cleaning/disinfecting chemicals from contacting the patient and staining clothing or irritating the skin. 2
To learn more about this topic, you will also find CDC Guidelines: From Policy to Practice by OSAP to be helpful. More information about this publication can be accessed at https://osap.site-ym.com/store/view_product.asp?id=396090 . 3
1) Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM, Centers for Disease Control and Prevention (CDC). Guidelines for infection control in dental health-care settings—2003. MMWR Recomm Rep 2003;52(RR-17):1-61. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm Accessed on October 10, 2013.
2) Miller CH. Infection Control and Management of Hazardous Materials for the Dental Team, 5th edition. Elsevier/Mosby Publishers. Page 155.
3) Organization for Safety, Asepsis and Prevention. CDC Guidelines: From Policy to Practice by OSAP. Published by OSAP. https://osap.site-ym.com/store/view_product.asp?id=396090 Accessed on October 10, 2013.