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FAQ's X-Rays

Frequently Asked Questions (FAQs) on Dental Infection Control


Top|Instruments & Equipment|X-Rays

Frequently Asked Questions for X-Rays

Q If a patient has a tongue piercing, is it necessary for them to remove the barbell for an x-ray or treatment?

Q In processing x-ray film, what do you do when film does not fall out of its packet?

Q What do you do regarding an employee who is trying to get pregnant but insists on running the x-ray machine?

Q On the plastic bite pegs for the pano machines, do you cover them with plastic or do you change them between each patient and gas sterilize them? What if the patient bites through the plastic?

Q What is OSAP's suggestion to control the infection of digital dental x-ray sensors?

Q We recently purchased some new lead shields at our office. How do we properly dispose of the olds ones?

Q What information could you provide regarding cross contamination with regards to lead lined radiography aprons and thyroid collars in the dental office? Should the lead apron be placed with clean gloves or without gloves? What is the proper protocol for removing the lead apron from the patient? Should the patients disposable dental bib be left on the patient while taking radiographs? I have not found a consistent policy with regard to the processing of radiographs.

Q Radiography-film that is not barrier-protected. Our institution does not use barrier pouches. Our protocol is as follow: Once the x-rays are taken, the exposed film is dried of saliva and film is placed on a J-cloth outside operatory. The students are asked to Overlap J-cloth to contact both film surfaces. Is it correct to be able to handle the film packets now with bare hands?

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Q If a patient has a tongue piercing, is it necessary for them to remove the barbell for an x-ray or treatment?

A Although intraoral radiographs can be used on patients who cannot remove their barbells, they will show up on a panoramic film. All known tongue barbells can be removed for at least three hours without the piercing closing. Patients should be advised that intraoral piercings may pose a risk for potentially serious infections.(1,2)

References:
(1) Akhondi H, Rahimi AR. Haemophilus aphrophilus endocarditis after tongue piercing. Emerg Infect Dis [serial online] 2002. Available at http://www.cdc.gov/ncidod/EID/vol8no8/01-0458.htm
(2) Yale Bulletin and Calendar. Brain abscess case linked to tongue piercing. January 18, 2002 Volume 30, Number 15 . Available at http://www.yale.edu/opa/v30.n15/story11.html

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Q In processing x-ray film, what do you do when film does not fall out of its packet?

A If the outer packet is pulled back completely, this should not occur. On the rare occasion that the film does not release from the packet, either place a clean glove on one hand to remove the film or use a clean cotton forceps to remove it from the package.

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Q What do you do regarding an employee who is trying to get pregnant but insists on running the x-ray machine?

A All workers must follow precautions to prevent occupational exposure to radiation emitted from dental x-ray machines. These precautions include ensuring the machines are properly collimated, the worker is never present in the room during exposure of the film, the worker is not in the path of the active beam, the worker is at least 6 feet from the active beam, the proper kVp and MA are utilized, and the highest speed film is used to further reduce the amount of radiation needed to expose the film. Additionally, monitoring exposure through the use of radiation monitoring badges may be considered. No specific restrictions are recommended for pregnant dental workers and each individual should consult their physician for recommended work restrictions.

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Q On the plastic bite pegs for the pano machines, do you cover them with plastic or do you change them between each patient and gas sterilize them? What if the patient bites through the plastic?

A Ideally, disposable pano bite pegs/guides or reusable guides that can be heat sterilized would be preferred. However, bite pegs/guides, chin rest, head positioning guides, and hand grips may be barrier protected.

We would also like to include additional information from the CDC's Infection Control Guidelines for Dental Healthcare Settings. Although it does not specifically mention pano bite pegs/guides, it does address radiograph accessories. In part, the guidelines state the following:

When taking radiographs, the potential to cross-contaminate equipment and environmental surfaces with blood or saliva is high if aseptic technique is not practiced. Heat-tolerant versions of intraoral radiograph accessories are available and these semi-critical items (e.g. film-holding and positioning devices) should be heat sterilized before patient use. (1)

Digital radiography sensors and other high-technology instruments (e.g., intraoral camera, electronic periodontal probe, occlusal analyzers, and lasers) come into contact with mucous membranes and are considered semi-critical devices. They should be cleaned and ideally heat-sterilized or high-level disinfected between patients. However, these items vary by manufacturer or type of device in their ability to be sterilized or high-level disinfected. Semi-critical items that cannot be reprocessed by heat sterilization or high-level disinfection should, at a minimum, be barrier protected by using an FDA-cleared barrier to reduce gross contamination during use. Use of a barrier does not always protect from contamination. One study determined that a brand of commercially available plastic barriers used to protect dental digital radiography sensors failed at a substantial rate (44%). This rate dropped to 6% when latex finger cots were used in conjunction with the plastic barrier. To minimize the potential for device-associated infections, after removing the barrier, the device should be cleaned and disinfected with an EPA-registered hospital disinfectant (intermediate-level) after each patient. (1)

Manufacturers should be consulted regarding appropriate barrier and disinfection/sterilization procedures for digital radiography sensors, other high-technology intraoral devices, and computer components. (1)

OSAP's Infection Control In Practice, November 2003 issue, states that intraoral x-ray accessories such as film-holding and positioning devices are classified as semi-critical items. Whenever possible, use disposable bite guides and other x-ray accessories. Heat-tolerant versions of these devices also are commercially available. (2)

Heat-sensitive semi-critical instruments that cannot be reprocessed by heat sterilization or by high-level chemical disinfectant/sterilant should be barrier protected to minimize contamination during use. After use, remove the barrier and clean and intermediate-level disinfect the intraoral surfaces of the device between patient uses. (2)

Resources:

1) CDC's Infection Control Guidelines for Dental Healthcare Settings:

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

2) Infection Control In Practice: Infection Control and Dental Radiography, Vol. 2, No. 8

November 2003 issue

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Q What is OSAP's suggestion to control the infection of digital dental x-ray sensors?

A First and foremost, you should follow the manufacturer's directions. The warranty may not be honored if the manufacturer's directions are not followed.

The August 2002 issue of Dental Products Report includes an article written by infection control expert Chris Miller, PhD. The article title is: "High-tech equipment: Keeping it germ-free".

Dr. Miller offers advice on questions to ask before buying equipment, precautions for special equipment, and general approaches to equipment decontamination. Dr. Miller does provide information in this article about digital radiography equipment. Following is a summary:

Because they are reusable, it is important to properly handle the sensors in order to prevent cross-contamination. There are three different types of sensors. These include:

(1) The charged-couple-device (CCD ) sensor. This sensor is attached to a cable and should not be heat-sterilized. This sensor should be covered with a fresh barrier extending down from the cable that prevents any contact with patient materials or contaminated hands. According to Dr. Miller, if the CCD should become contaminated, it may be disinfected using the spray-wipe-spray technique according to manufacturer's directions. This involves spraying on a disinfectant and wiping with a gauze pad, then spraying again (following the contact time indicated on the disinfectant label). Then rinse off the disinfectant with water and let dry.

(2) The complementary metal-oxide semiconductor with active pixel sensors (CMOS/APS).
It is wired and should be treated with plastic barriers according to manufacturer's
directions, just like the CCD sensor.

(3) The third type of sensor is the Photo-Stimulable Phosphor Plate (PSP) sensor. The
sensor is wireless and is placed in the patient's mouth, much like regular film. This
sensor should be covered with a fresh barrier for each use. Care must be taken not to
tear the barrier inadvertently during use because it cannot be heat-sterilized or
chemically disinfected. (See manufacturer's information for specifics). (1)

The Centers for Disease Control and Prevention's Infection Control Guidelines for Dental Healthcare Settings state:

Digital radiography sensors and other high-technology instruments (e.g., intraoral camera, electronic periodontal probe, occlusal analyzers, and lasers) come into contact with mucous membranes and are considered semi-critical devices. They should be cleaned and ideally heat-sterilized or high-level disinfected between patients. However, these items vary by manufacturer or type of device in their ability to be sterilized or high-level disinfected. Semi-critical items that cannot be reprocessed by heat sterilization or high-level disinfection should, at a minimum, be barrier protected by using an FDA-cleared barrier to reduce gross contamination during use. Use of a barrier does not always protect from contamination. One study determined that a brand of commercially available plastic barriers used to protect dental digital radiography sensors failed at a substantial rate (44%). This rate dropped to 6% when latex finger cots were used in conjunction with the plastic barrier. To minimize the potential for device-associated infections, after removing the barrier, the device should be cleaned and disinfected with an EPA-registered hospital disinfectant-- intermediate-level (tuberculocidal) after each patient. Manufacturers should be consulted regarding appropriate barrier and disinfection/sterilization procedures for digital radiography sensors, other high-technology intraoral devices, and computer components. (2)

Additionally, the United States Air Force's Dental Evaluation and Consultation Service provides the following information:

At this time, however, there are no sensors that can withstand heat sterilization or complete immersion in a high-level disinfectant. (3)

Because the sensors and associated computer components vary by manufacturer and are expensive, manufacturers should be consulted regarding specific disinfection products and procedures. (3)

http://www.airforcemedicine.af.mil/decs/

Resources:

1) Dental Products Report. August 2002: "High-tech equipment: Keeping it germ-free". By Chris Miller, PhD.

2) Centers for Disease Control and Prevention's Infection Control Guidelines for Dental Healthcare Settings:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217.a1.htm

3) United States Air Force Dental Evaluation and Consultation Service:

http://www.airforcemedicine.af.mil/decs/

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Q We recently purchased some new lead shields at our office. How do we properly dispose of the olds ones?

A First and foremost, lead must be disposed of according to all federal, state, and local laws/regulations. OSAP does not maintain state/local laws, or regulations, therefore, check with your State Environmental Protection Agency—solid waste division (EPA) and State Board of Dental Examiners/Licensing Board for current federal, state, and local regulations governing lead disposal in your state. There also may be state and local health regulations (due to the lead content) that OSAP would not be aware and your State Health Department/Agency should be contacted as well. You may also contact a licensed waste hauler in your area for additional information on proper disposal.

Typically, lead should be segregated and placed in a clearly labeled lead waste container to await disposal or recycling by a properly licensed waste hauler. But again, lead must be handled and disposed of according to your state/local laws.

OSAP provides links to individual state agencies at: http://www.osap.org/resources/links

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Q What information could you provide regarding cross contamination with regards to lead lined radiography aprons and thyroid collars in the dental office? Should the lead apron be placed with clean gloves or without gloves? What is the proper protocol for removing the lead apron from the patient? Should the patients disposable dental bib be left on the patient while taking radiographs? I have not found a consistent policy with regard to the processing of radiographs.

A 1. Contaminated patient bibs should be removed prior to placement in order to avoid contamination of the underside of the lead apron/thyroid collar.

2. Lead aprons/thyroid collars may be placed with clean hands or one may choose to wear clean exam gloves.

3. Contaminated gloves should be removed and hands washed prior to removing the lead apron/thyroid collar. Because the lead apron may have become contaminated you should wear new exam gloves or over-gloves when removing the lead apron.

4. Lead aprons/thyroid collars should be cleaned and disinfected after each patient use. You should consult the manufacturer for a list of acceptable cleaning and disinfecting products that may be used on their aprons/collars.

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Q Radiography-film that is not barrier-protected. Our institution does not use barrier pouches. Our protocol is as follow: Once the x-rays are taken, the exposed film is dried of saliva and film is placed on a J-cloth outside operatory. The students are asked to Overlap J-cloth to contact both film surfaces. Is it correct to be able to handle the film packets now with bare hands?

A No, bare hands should not be used. Even though you have placed them on a J-cloth the film packets are still contaminated.

We would like to refer you directly to the Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental Healthcare Settings. The guidelines, in part, state the following:

When taking radiographs, the potential to cross-contaminate equipment and environmental surfaces with blood or saliva is high if aseptic technique is not practiced. Gloves should be worn when taking radiographs and handling contaminated film packets. Other PPE (e.g., mask, protective eyewear, and gowns) should be used if spattering of blood or other body fluids is likely. Heat-tolerant versions of intraoral radiograph accessories are available and these semicritical items (e.g., film-holding and positioning devices) should be heat-sterilized before patient use. (1)

After exposure of the radiograph and before glove removal, the film should be dried with disposable gauze or a paper towel to remove blood or excess saliva and placed in a container (e.g., disposable cup) for transport to the developing area. Alternatively, if FDA-cleared film barrier pouches are used, the film packets should be carefully removed from the pouch to avoid contamination of the outside film packet and placed in the clean container for transport to the developing area. (1)

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

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