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264 General Dentistry www.agd.org

InfectionC

ontrol

Since the beginning of the AIDS epidemic,

an increased emphasis has been placed on

medical and dental work practices to min-

imize bloodborne pathogen exposure. In

1990, public concern regarding dental in-

fection control grew after the CDC report-ed a possible clinic-acquired HIV trans-

mission within the dental setting.1 In

1991, OSHA established the Bloodborne

Pathogens Standard to protect employees

from exposure to potential pathogens in

human body fluids.2 This document man-

dated that personal protective measures be

implemented in health care settings to

safeguard employees who could come in

contact with potentially infectious materi-

als, including blood or saliva.

Dental patients and dental health care

workers (DHCWs) are exposed to a num-

ber of infectious disease agents during thedelivery of treatment. To minimize the

risk of cross-contamination (that is, the

passage of microorganisms from one per-

son or inanimate object to another) that

may transmit disease, both the CDC and

the ADA have published dental infection

control guidelines, which are revised peri-

odically to include the most updated

information.3,4

Because blood and saliva can harbor

life-threatening microbes, health care

workers providing dental care may be ex-

posed to a variety of pathogens (see

Table 1). Studies have shown that opera-tory equipment, surfaces, and materials

used during treatment can become heav-

ily contaminated through cross-contami-

nation from saliva and blood-coated

hands as well as gloved hands, which can

serve as a source for the indirect spread of

microorganisms.5-8 Infection control

practices are designed to create and

maintain a safe clinical environment to

eliminate or minimize disease transmis-

sion during patient treatment.

In an effort to reduce transmission of

bloodborne pathogens between DHCWs

and patients, in 1988 the CDC empha-

sized the use of Universal Precautions,

meaning that all patients should be con-

sidered potentially infectious and that thesame infection control procedures should

be used for every dental procedure where

a DHCW could come into contact with

blood or saliva.9 In 1996, the CDC devel-

oped guidelines combining Universal

Precautions and body substance isola-

tion. These guidelines are known as

Standard Precautions, which consider all

body fluids, secretions, and excretions

(except sweat) as potentially infectious,

regardless of whether they contain

blood.10 Initially developed for use in the

care of patients in hospitals, Standard

Precautions gradually have replaced Uni-versal Precautions in all types of health

care settings.

To prevent or reduce the risk of work-

related infections for DHCWs and their

patients, all dental facilities should have a

well-written, frequently updated infec-

tion control plan. The plan should in-

clude policies and standard operating

procedures for patient care, including

dental radiology.

Infection control practices for dental

radiography, like those utilized in the

dental operatory, are based on Standard

Precautions. The potential for cross-con-tamination in dental radiology is ex-

tremely high, because taking and process-

ing intraoral radiographs involves a

multi-step process including both intra-

oral and extraoral procedures.

Several studies have confirmed that

cross-contamination occurs during the

exposure and processing of intraoral

films. Rahmatulla et al found that most

high-touch areas in dental radiology, in-

cluding the dental chair headrest adjust-

ing lock, the x-ray cone, the exposurecontrol knob, the timer switch, the x-ray

film placement area in the darkroom, the

x-ray film feeding area in the automatic

film processor, and the revolving door to

the darkroom, became contaminated

while taking radiographs.11 White and

Glaze found that the DHCW can transfer

oral microorganisms from the patients

oral cavity to radiographic equipment

during routine intraoral radiography.12

These microorganisms remain viable on

radiographic equipment for at least 48

hours. Bachman et al demonstrated thatcontaminated films cross-contaminate

radiographic processor equipment, be-

cause the developing process does not de-

stroy the microorganisms.13

Bacteria can survive in used dental

radiographic developer and fixer for up

to two weeks.14 A 1993 report by Stan-

czyk et al discovered that microorganisms

on contaminated radiographic film can

survive the processing cycle, meaning sub-

sequent films frequently become cross-

contaminated within the processor.15 In

addition, the processor and daylight loader

could become contaminated and remainso even after 48 hours of inactivity.15

A number of articles offer suggestions

and specific information regarding proper

infection control procedures for exposing

and processing dental radiographs.16-36 As

mentioned earlier, infection control prac-

tices in dental radiology are similar to

those used in the dental operatory, in-

cluding the wearing of appropriate per-

sonal protective equipment; handwash-

ing; using surface barriers; cleaning and

disinfecting equipment and environmen-

tal surfaces; and cleaning, disinfecting,

and sterilizing instruments. Each of theseprocedures will be discussed in detail.

Personal protective equipm entAll DHCWs should wear gloves to prevent

skin contact with blood, saliva, mucous

membranes, and contaminated items or

surfaces. Gloves also should be worn when

taking intraoral radiographs and when

handling contaminated film packets,

equipment, supplies, and instruments.

Powder-free gloves are recommended

The potential for cross-contamination in dental radiology is extremely high, especiallywhen intraoral radiographs are exposed and processed. This report describes specific

infection control practices that are recommended to decrease the potential for cross-

contamination in dental radiology and reduce the likelihood of disease transmission.

Received: February 21, 2002 Accepted: April 30, 2002

Infection control practices in dental radiology

Joseph A. Barto lon i, DMD | David G. Charlton, DDS, MSD | Dian e J. Flint , DDS

D A R TDental Article Review and Testing

Two hours of CDE credit

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because powder can affect the films

emulsion layer and cause image artifacts.

Gloved DHCWs should either avoid

touching nonbarrier-protected surfaces

or use an overglove, such as an oversized

food handlers plastic glove. Gloves are

single-use items and should be changed

between patients; they should never be

washed or disinfected for reuse and

should be removed and changed if they

become torn, cut, or punctured during

treatment. It usually is not necessary to

wear impervious gowns, long sleeves,

masks, or protective eyewear during rou-

tine dental radiology procedures as long

as no aerosols, droplets, or spatter are

generated, although these should be con-

sidered when treating patients with gag-ging problems or respiratory infections,

such as the common cold.

HandwashingProper handwashing is one of the most

important means of preventing disease

transmission. All DHCWs should wash

their hands thoroughly before and after

patient treatment (that is, before gloving

and after removing gloves). Ungloved

hands should be washed after touching

any contaminated item or surface. Gloves

are not a substitute for handwashing.

Surface barriersAny surfaces and objects that may be

touched by contaminated gloved hands

during treatment should be covered with

some type of disposable, impervious bar-

rier such as household plastic wrap, a

plastic bag, plastic sheets or tubing, or

aluminum foil. Surface barriers provide

adequate protection against cross-con-

tamination while eliminating the need to

clean and disinfect surfaces between pa-

tients, which has the additional benefit of

reducing turnaround time. If uncovered

surfaces are contaminated, they should

be disinfected after the patient leaves.

Contaminated surface barriers should be

changed between patients and gloves

should be worn when removing and dis-

carding surface barriers.

Cleaning and disinfection ofequipment and environmentalsurfacesFollowing a patients treatment, all sur-

faces and items contaminated with blood

or saliva should be thoroughly cleaned

and disinfected using a suitable chemical

germicide that provides intermediate-

level disinfection. By definition, interme-diate-level disinfectants destroyMycobac-

terium tuberculosis, hydrophilic and

lipophilic viruses, fungi, and vegetative

bacteria but not bacterial spores. Chem-

ical germicides appropriate for use in

dental facilities should be labeled hospi-

tal-grade and have an EPA number.

Hospital-grade germicides demonstrate

efficacy against Staphylococcus aureus,

Pseudomonas aeruginosa, and Salmonella

choleraesuis. They also should be tuber-

culocidal, capable of killingM. tuberculo-

sis. The manufacturers instructions

should be followed carefully with regardto dilution, use, and material compatibil-

ity. Heavy-duty utility gloves should be

worn when using chemical germicides.

Cleaning, disinfection, andsterilization of instrum entsand itemsMost reusable instruments and items

used in dental radiology are considered

semicritical (contacting the mucous

membrane) or noncritical (contacting in-

tact skin). Reusable semicritical items

such as x-ray film holding and position-

ing devices should be barrier-protected or

treated with a high-level disinfectant at

the very least. High-level disinfectants are

capable of destroying or inactivating all

microbial life (including bacterial spores)

as long as they are used in sufficient con-

centrations and with appropriate contact

times; however, reusable semicritical

items should be sterilized between patient

use. If routine sterilization of semicritical

items is not possible, disposable items

should be substituted. Noncritical items

(for example, the x-ray cone, exposure

button, and lead apron) require only in-

termediate-level disinfection.

The exposure and processing of intra-oral radiographs are not routinely associ-

ated with blood and saliva splatter but dis-

ease transmission still is possible through

direct contact or cross-contamination.

Therefore, specific infection control prac-

tices for dental radiology are recommend-

ed that should be followed before, during,

and after film exposure as well as during

the processing of intraoral radiographs.

Prior to film exposure, the x-ray expo-

sure area should be prepared using an

aseptic technique, one which breaks the

chain of infection and prevents cross-con-

tamination. All necessary supplies, equip-ment, and instruments should be pre-

pared before the patient is seated; only the

amount necessary for each procedure

should be dispensed. This concept,

known as unit dosing, is essential for min-

imizing cross-contamination (Fig. 1).

Unit dosing reduces both chairside time

and the DHCWs contact with environ-

mental surfaces.

The DHCW should barrier-protect

all surfaces that are likely to be touched

Bacteria VirusesMycobacterium tuberculosis HIV

Streptococcus pyogenes Hepatitis B

Streptococcus pneumoniae Hepatitis C

Staphylococcus aureus Herpes simplex 1 and 2

Staphylococcus epidermis Cytomegalovirus

Haemophilus influenza Epstein-Barr

Treponema pallidum Measles rubeola/rubella

Neisseria gonorrhoeae Cold/flu

Varicella-zoster

Table 1. Microorganisms that may be present in blood or saliva.

Fig. 1. To minimize cross-contamination,

only those items necessary for the procedure

should be dispensed. This process is known

asunit dosing.

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during the radiographic procedure (seeTable 2). Figures 24 show the proper

use of barriers on radiographic equip-

ment. As with other operatory equip-

ment, using a foot switch or a wrapped,

hand-held remote switch with the x-ray

unit can reduce contact and minimize

cross-contamination (Fig. 5 and 6).

Dental radiographic film should be

dispensed aseptically from a central sup-

ply area and placed in a disposable con-

tainer, such as a paper cup or plastic bag

(Fig. 7). Other items that should be dis-pensed aseptically from a central supply

area include reusable film-holding devices

(which also should be packaged and ster-

ilized between patient use); cotton rolls

(to stabilize film placement); and paper

towels, which can remove excess saliva

from exposed films and protect work sur-

faces where film could be placed after ex-

posure. Tables 35 list proper infection

control practices before, during, and after

exposure and during processing. Table 6

lists infection control practices duringfilm processing.

Handling films with andwithout barriersFilm barriers offer a simple method for

maintaining proper infection control

measures when using a daylight loader.

Tests have shown that film barr iers,when

placed correctly, prevent the penetration

of fluids.34 Commercially available film

barriers such as ClinAsept (Eastman


Tubehead/yoke

X-ray cone

Control panel

Exposure button

Headrest

Headrest adjustment control

Chair adjustment control

Work area or countertop

Table 2. Surfaces thatshould be protected prior toradiographic procedures.

Before the patient is seatedThe DHCW should unit dose the follow-ing items: preprocedural mouthr inse;

paper towels; surface disinfectant; surfacebarriers; powder-free gloves; radiograph-ic film(s); sterile or disposable film hold-ers; paper cups or plastic bags; over-gloves; lead apron with thyroid collar;and cotton rolls.

The patient should rinse with a preproce-dural mouthrinse to reduce the numberof oral microorganisms and minimize thepotential for cross-contamination viadirect contact.

After the patient is seatedAdjust the headrest and chair position.

Place the lead apron with thyroid collar.

Have the patient remove any items thatmay interfere with film exposure (eye-glasses, dentures, and so forth) .

After completing these procedures, theDHCW should wash his or her handsthoroughly and don gloves. If usingreusable film-holding devices, theyshould be removed from the sterilizedpackage and assembled. All of thesesteps should be performed in the pa-tients presence.

Table 3. Infection control practices before film exposure.

Fig. 2. Surface barriers covering

the tubehead/yoke, x-ray cone,

and headrest.

Fig. 3. A surface barrier cover-

ing the tubehead and x-ray cone.

Fig. 4. A surface barrier covering the

control panel of an x-ray machine.

Fig. 5. A foot switch, used to

activate the exposure while

maintaining infection control.

Fig. 6. A surface barrier

completely enclosing the

remote switch.

Fig. 7. Aseptic dispensing

of dental radiographic film

prior to the procedure.

Fig. 8. Film barriers. Left: film placed in a

barrier. Right: prepackaged film with a

ClinAsept barrier.

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Kodak, Rochester, NY; 800/933-8031),

which may be purchased with the film in-

serted into the barrier, can protect the

film packets from contamination while

also reducing both preparation and pro-

cessing time. Alternatively, dental facili-

ties can purchase film barr iers separately

and insert the film into the barrier prior

to the radiographic procedure (Fig. 8).

Other options include using a finger cot

The DHCW should touch as few surfaces as possible; those surfaces should be barr ier-protected.

Dry each film with a paper towel after taking it from the patients mouth to removeexcess saliva.

Place the film in a disposable container such as a paper cup or plastic bag beforetransporting it to the processing area (Fig. 13).

Do not touch the disposable container while wearing contaminated gloves.

During exposures, film-holding devices should be transferred to a covered work sur-face protected by a surface barrier.

If the DHCW must leave the work area during film exposure, gloves must be removedand hands washed. Before resuming with film exposures, the hands should be washedagain and new gloves donned.

Table 4. Infection control practices during film exposure.

After use, reusable film-holding devices should be placed in an area designated forcontaminated instruments.

All disposable contaminated items (for example, cotton rolls, bitewing tabs, papertowels, and surface barr iers) should be discarded in accordance with local and stateenvironmental regulations; gloves should be worn when handling them.

The DHCW should unwrap all covered surfaces carefully while ensuring that the un-derlying surface remains untouched with the contaminated gloves.

The gloves should be removed and hands washed once all contaminated items are re-moved and disposed. At that point, the lead apron may be removed and the patientdismissed from the x-ray exposure area.

Any uncovered areas that were contaminated during the procedure should be cleanedand disinfected using an EPA-registered, hospital-grade, tuberculocidal disinfectant.Because these disinfectants can be skin irr itants, DHCWs should wear ut ility gloves

when using them. Remember that chemical germicides may affect the control panelselectrical connections, so avoid applying them too liberally.

Table 5. Infection control practices after film exposure.

Exposed films should be transported to the processing area in a disposable containersuch as a paper cup or plastic bag. The container should never be touched with con-taminated, gloved hands.

Prior to taking the films to the processing area, the gloves should be removed, thehands washed, the area cleaned up, and the patient dismissed.

The following items should be unit dosed in the processing area prior to starting the pro-cessing procedure: gloves; paper towels; paper cups; and film mount or paper envelope.

The gloves,paper towels,and paper cups are necessary for film handling prior to processing.

A paper envelope or film mount is used to hold and store the film(s) after processingand should be labeled with the patients name and date.

Table 6. Infection control practices for film processing.

Fig. 10. Technique for aseptically removing

a dental radiographic film from its barrier

and allowing it to fall into a paper cup.

Fig. 9. Barrier-protected fi lm, opened care-

fully and allowed to drop onto a paper towel

to prevent contamination.

Fig. 11. Using a surface barrier to cover

the bite guide and chin rest of a panoramic

machine.

Fig. 12. Digital sensor covered with a plastic

sheath and a latex finger cot.

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as a barrier or heat-sealing plastic wrap

around the film. Film barriers should be

opened carefully in a lighted area using

gloved hands. The film packet should be

dropped onto a paper towel or into a

paper cup for transport to the processing

area (Fig. 9 and 10); once the film packetis in the processing area, it may be

opened in the conventional manner us-

ing ungloved, clean hands.

Tables 7 and 8 list the recommended

steps when handling films with or with-

out film barriers.

Daylight loadersDaylight loaders usually have cloth or rub-

ber sleeves,cuffs, or flaps to allow access to

the chamber while minimizing light expo-

sure. These units present an additional

challenge when processing contaminated

film packets because of the potential for

cross-contamination in the access open-

ings of the chamber. Table 9 lists steps rec-

ommended for processing nonbarrier-

protected films in an automatic film

processor with a daylight loader.

Panoramic/cephalometricimagingBecause contamination from blood or

saliva is highly unlikely during extraoral

radiographic procedures, the infection

control practices that should be followed

are rather simple (see Table 10). Themain infection control concern when

taking a panoramic radiograph is the bite

guide. This item can be handled in sever-

al ways, including barrier-protecting it

with a surface barrier (Fig. 11) or finger

cot, using a disposable bite guide, or ster-

ilizing a reusable bite guide between each

patient use.

Digital imagingDigital radiography is becoming more

common in dent istry, as it is considered

to offer advantages such as reduced pa-

tient radiation exposure, faster imagingdisplay, elimination of film and dark-

room armamentarium, the ability to

transmit images electronically, ease of

image storage,and the ability to manipu-

late the images.37 For digital radiography,

the equipment located in the operatory

includes a receptor, central processing

unit (CPU), keyboard, monitor, mobile

cart, and possibly a printer. These items can

become contaminated with aerosols and

spatter generated from dental procedures

Place a paper towel on the work surface.

Place the disposable container containing the films next to the paper towel.

Secure the door and turn out the darkroom lights (if applicable).

Don gloves.

Remove one contaminated film from the container.

Open the film packet tab, slide out the lead foil backing and black paper, and discardthe film packet wrapping.

Rotate the lead foil away from the black paper and discard as per local/state regulations.

Open the black paper wrapping without touching the film and allow the film to droponto the paper towel (Fig. 14).

Discard the black paper wrapping.

Discard the container after all film packets have been opened.

Remove gloves and wash hands.

Process films, handling them by their film edges.

Label a film mount or paper envelope with the patients name and date and use it tohold the processed films.

Any area touched by contaminated, gloved hands should be cleaned and d isinfected.

Table 8. Recommended steps for handlingfilms not protected by film barriers.

Place a paper towel on the work surface.

Next to the paper towel, place the disposable container containing the films.

Don gloves.


Open the film barrier, carefully avoiding contact with the film packet.

Allow the film packet to drop onto the paper towel.

Dispose of the film barr ier.

After all film barriers have been opened, dispose of the container.

Remove gloves and wash hands.

Secure the door and turn out the darkroom lights (if applicable).

Unwrap and process the films, handling them by the film edges only.

Label a film mount or paper envelope with the patients name and date, using it tohold the processed films.

Table 7. Procedure for handling films with film barriers.

Fig. 13. Exposed film is placed in a paper

cup for transport.

Fig. 14. Technique for removing a dental

radiographic film aseptically from its black

wrapper and allowing it to drop onto a

paper towel.

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and should be protected.

The CPU should be barrier-protected

except for the air vent, to prevent overheat-

ing. A foot switch can minimize contact

with the CPU switches. A commercial

vinyl keyboard cover should be used to

protect the keyboard. The keyboard cov-er then should be barrier-protected with

plastic wrap, which is changed between

patients. The monitor may be wrapped

in high-touch areas only; avoid covering

the air vents that cool the tube. A screen

shade will prevent aerosols from contam-

inating the monitor screen; if the screen

is visibly soiled, it should be cleaned and

disinfected with an intermediate-level

disinfectant. If a printer is used in the

operatory, it also should be barrier-pro-

tected with plastic wrap. Again, avoid

covering the air vents that prevent heat

buildup.

There are two basic types of receptors:

direct sensors, which are attached to the

computer monitor via a cable, and stor-

age phosphor plates, which resemble in-

traoral film but are reusable and

processed in a scanner. Both types of re-

ceptors can become contaminated dur ing

image exposure and handling. Unfortu-

nately, neither receptor can be auto-

claved, so it is important to use effective

barrier techniques. Digital system manu-

facturers recommend plastic sheaths for

preventing cross-contamination.Two recent studies have shown re-

duced rates of direct sensor cross-con-

tamination by augmenting the plastic

sheath provided by the manufacturer

with a latex finger cot (Fig. 12).38,39 Stor-

age phosphor plates require a barrier

provided by the manufacturer and

should be handled as described previous-

ly for intraoral films. There are no stan-

dardized infection control practices for

digital radiography at present, but new

technologies are being developed to facil-

itate infection control, including rubber

keyboards, keyless keyboards, and flat-panel touchscreens.

SummaryInfection control has become a signifi-

cant part of dentistry. Dental employers

should ensure that their employees com-

ply with the current mandates of Stan-

dard/Universal Precautions. In addition,

all dental offices and clinics should devel-

op a written infection control plan that

describes specific practices to prevent the

Prior to taking an extraoral radiograph, the DHCW should wash his or her hands.

The patient should rinse with a preprocedural mouthwash before the procedure. Ifbarriers are used, they should be placed before positioning the patient. After the pro-cedure, ask the patient to remove the barrier on the bite guide (or the disposable biteguide) and place it in the regular waste bin.

If this procedure is performed by the DHCW, he or she should don gloves before re-moving the contaminated item. The gloves should be discarded and hands washedprior to handling the film cassette.

For hygienic purposes, the patient chin rest, head-positioning guides, and handgrips canbe barrier-protected or cleaned after film exposure. Since patient secretions normally donot contaminate extraoral cassettes, cassettes can be handled with ungloved hands.

No other infection control steps are necessary for processing.

Table 10 . Infection control practicesduring extraoral radiographic procedures.

Place a paper towel on the surface inside the daylight loader compartment.

Place a paper cup and powder-free gloves in the daylight loader compar tment.

Place the container with contaminated films next to the paper cup (Fig. 15).Close the daylight loader lid and place hands through the sleeves.

Don gloves.


Open the film packet as described in Table 8.

Allow the film to drop onto the paper towel or processor film feed slot.

Dispose of the film packet contents in the empty paper cup.

After all film packets have been opened, remove gloves and place them in the paper cup.

Feed all unwrapped films into the processor,handling them only by their edges (Fig. 16).

Remove hands from daylight loader.

Wash hands.

Lift the lid of the daylight loader to remove all contents.

Label a film mount or paper envelope with the patients name and date, using it tohold the processed films.

Table 9. Steps for processing nonbarrier-protected fi lmsin an automatic film processor having a daylight loader.

Fig. 15. Unit dosing of a paper towel,

powder-free gloves, and an empty paper

cup. The paper cup with the contaminated

films also is placed inside the daylight loader

compartment.

Fig. 16. Proper method for handling films

as they are fed into the automatic processor.

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transmission of infectious diseases

through direct contact and cross-con-

tamination. The key to preventing cross-

contamination in dental radiology is to

practice proper asepsis to break the chain

of transmission of patient contaminants

(that is, blood and/or saliva) from theoral cavity to surfaces and items used

and/or touched during the radiographic

procedure. Specific infection control

practices are recommended before, dur-

ing, and after film exposure and during

the processing of intraoral radiographs

to prevent cross-contamination. Infec-

tion control practices are changing con-

stantly and it is important that dental

staff members stay abreast of these

changes.

The infection control practices out-

lined here describe a simple, efficient

asepsis protocol for the entire dental staff

to follow during dental radiographic pro-

cedures to prevent cross-contamination.

There is no direct evidence suggesting

that the spread of oral microorganisms

during a radiographic procedure is a

major cause of disease transmission

between DHCWs and patients but the

possibility cannot be ignored. The poten-

tial for cross-contamination in dental ra-

diology is very high but using effective

infection control practices can reduce

this potential significantly, protecting

both patients and staff.

DisclaimerThe views expressed in this article are

those of the authors and do not reflect

the official policy of the Department of

Defense or other departments of the

United States Government.

Author InformationCol Bartoloni is Director, Professional

Services at the USAF Dental Investigation

Service, Naval Training Center, Great

Lakes, Illinois, where Col Charlton is Di-

rector, Materials Evaluation. Dr.Flint is aPostdoctoral Fellow in Oral and Maxillo-

facial Radiology at the University of Texas

Health Science Center, San Antonio.

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