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4 CEUsThis course was

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Breaking the Chain of Infection: Practical and Effective Infection ControlA Peer-Reviewed Publication Written by Nancy Andrews, RDH, BS

This course has been made possible through an unrestricted educational grant from Kerr TotalCare®. The cost of this CE course is $59.00 for 4 CEUs. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting the Academy of Dental Therapeutics and Stomatology in writing.

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Educational ObjectivesAt the completion of this course, the dental healthcare profes-sional (DHCP) will be able to:1. Understand the “chain of infection” and how infec-

tion control strategies break that chain or prevent infection transmission.

2. Discuss the roles of the following methods in breaking the chain of infection: hand hygiene, instrument processing, environmental asepsis, and personal protective barriers.

3. Describe the concept of cleaning prior to disinfection or sterilization relative to hand hygiene, instrument processing, environmental asepsis, and personal protec-tive barriers.

4. Understand how to select and use appropriate products correctly.

IntroductionAll dental procedures provide an opportunity to transmit infectious pathogens directly or indirectly between patients and workers. The pathway of disease transmission between people is referred to as the “chain of infection,” and infection control programs focus on breaking this “chain.” This educa-tional course addresses hand hygiene, instrument processing, environmental asepsis, and use of personal protective barri-ers relative to breaking the chain of infection, undertaking sequenced processes of cleaning prior to disinfection or steril-ization, and using appropriate products correctly. Single-dose and disposable products as alternatives to bulk or re-usable items and their roles in addressing the goals of safety and ef-ficiency are also considered.

Disease transmission requires a source of microbes, a method of transmission and exposure, an entry portal, and a susceptible host. Microbial exposure can be direct or indirect. Direct exposure may occur through injury or contact with non-intact skin, mucosal tissue, or ocular tissue or through ingestion. Examples of direct and indirect transmission are shown in Table 1. Hand contact with contaminated surfaces is an example of indirect contact and can result in cross-con-tamination, endangering patients and staff alike. Both contaminated surfaces and aerosols generated during dental

procedures have been found to pose a serious exposure hazard for DHCPs.1

Infection Control Program StrategiesA well-structured infection control program provides maxi-mum protection for patients and staff while enabling the of-fice to operate efficiently, but does not eliminate the risk of exposure. Infection control strategies attempt to break the “chain of infection” in many places along the pathway of disease transmission, with an emphasis on the earliest op-portunities to control pathogen contamination. Controlling the spread of pathogens at the source rather than allowing pathogen dispersal makes infection control more manageable and probably more successful. The strategy of breaking the chain of infection before exposure occurs is proactive and requires planning, training, and a commitment to avoiding exposure. If contamination has already occurred, cleaning followed by disinfection or sterilization is necessary. Infection control programs should be clearly written, must adhere to legal requirements, and should be well-monitored on a day-to-day basis.2

Breaking the “chain of infection” and preventing disease transmission

Hand HygieneOne of the most common methods for microbial transmis-sion is through contamination by hands as a result of poor hand hygiene, which has been linked to healthcare-associated infections. These findings were a major motivation for CDC Infection Control Recommendations in 2003. Appropriate hand hygiene has been found to be the single most critical procedure in the infection control program.3 Normal human skin is colonized with millions of bacteria. Resident flora, found in the deeper layers of the skin, is unique to each in-dividual and is less likely than the more superficial transient flora to be removed during hand antisepsis. Transient flora is acquired through contact with microbes on people, items, or surfaces, and is more commonly associated with healthcare-related infections, including pathogenic coagulase-resistant Staphylococcus aureus.

Hand hygiene is the single most critical procedure in the infection control program.

Personal and Surface BarriersBarriers are designed to prevent exposure. Intact skin is the first line of defense against infection. The second line of defense is the use of personal protection barriers. Avoiding personal exposure is preferable to the stress, time, and cost of responding to an exposure incident. Routine use of personal barriers to prevent pathogens from contacting mucosal tissues of the eyes, oronasal mucosa, or any openings in skin has been

Table 1.

Direct transmission — primary exposure

Needle-stick and sharps injuries

Injury from an instrument during a procedure

Spray or debris entering the eye

Bacterial aerosol and splatter during a procedure

Unprotected skin

Indirect transmission — secondary exposure

Contaminated instruments

Contaminated surfaces and equipment

Bacterial aerosol

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very successful in reducing DHCP exposure to infections, and is now “standard practice.” However, if workers become lax in their use of barriers such as wearing them out of position, wearing them past their lifespan, re-using single-use items, or failing to wear them, then infection is more likely to occur.

Masks were originally designed to protect the patient from contamination caused by the operator coughing, speaking, etc. Face shields, eyewear, and masks protect DHCPs from exposure to potentially infectious fluids and debris, as well as from injury due to flying particles. Patient treatment masks and respirators also filter breathed air. Dental professionals have been found to have higher rates of conjunctivitis than the non-dental population,4 highlighting the importance of protective eyewear.

Routine use of personal barriers is “standard practice.”

Surface/Environmental BarriersOperatory surface barriers prevent surface contamination by touch, contact, or airborne contaminants. Clinical contact surfaces frequently touched (such as light handles), and com-plex surfaces that are difficult or time-consuming to clean, can be covered with impermeable single-use barriers.

The benefits of surface barriers include: less time spent performing environmental asepsis, more reliable asepsis, and visible barriers that communicate asepsis to patients. Aseptic techniques are needed to handle and change barriers, and uncovered clinical contact surfaces must still be cleaned and disinfected between patients.

Surface Cleaning and DisinfectionAny exposed clinical contact surface should be first cleaned and must then be disinfected using intermediate-level dis-infectants (those that are effective against Mycobacterium tuberculosis — a highly resistant organism used to test sur-face disinfectants) between patients. Cultures of operatory surfaces have yielded a variety of microorganisms, including methicillin-resistant Staphylococcus aureus, and the transmis-sion of this pathogen to a number of patients occurred during dental procedures in one study.5 Hepatitis B transmission between patients has been documented, and the investigators speculated that a lapse in environmental asepsis procedures was the most likely mechanism of transmission.6 Both stud-ies highlight the importance of effective surface barriers and decontamination.

Instrument ProcessingInstrument processing must be appropriate to the pro-cedures for which the instrument or component is used. Heat-sterilizable and disposable items offer the highest level of asepsis to reliably prevent disease transmission and are required for critical instruments (those that penetrate the mucosa). For semi-critical instruments (those that contact the mucosa), immersion in high-level disinfectant/steril-ants may be acceptable if the instrument is heat-sensitive and cannot be otherwise sterilized.7 (Figure 1) Breaking the “chain of infection” requires a sequence of steps. Instrument processing is quicker, more controlled, and less error-prone with automated devices and processes such as instrument washers, ultrasonic cleaners, and current-model sterilizers — thereby reducing risk.

Breaking the chain of infection: Instrument Processing

Spray enzymatic foam onto non-disposable instruments and

trays to start cleaning process

Remove all non-disposable instruments to the instrument

processing area

Clean all non-disposable instruments

Store packaged, sterile instruments

Discard all sharps into sharps container; discard all

single-use items

Heat-sterilize all critical instruments, all heat-resistant semi-critical and non-critical

instruments

Perform the procedure: single-use disposable and

sterilized instruments

Chemical-sterilize all heat-sensitive semi-critical

and non-critical instruments

Figure 1. Breaking the chain of infection: Instrument Processing

Non-surgical procedures Surgical procedures

Prior to donning gloves

Instrument cleaning

Don medical gloves Don sterile surgical gloves Don thick utility gloves

Hands visibly soiled:Wash with water and plain

or antimicrobial soap

Hands not visibly soiled:Wash with water and plain

or antimicrobial soap OR use an alcohol-based hand-rub

Wash with antimicrobial soap OR wash with plain soap and use an alcohol-based

hand-rub with substantivity

Wash hands with water and plain or antimicrobial soap OR apply waterless hand sanitizer

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Single-use Disposable and Unit-dose ItemsDisposable and unit-dose products are becoming more available and economical. These offer time-saving alterna-tives to the sequential steps required in the processing of re-usable dental items and should avoid potential cross-con-tamination. Single-use disposable items cannot be sterilized or safely disinfected and must be discarded after one use and disposed of appropriately. Single-use sharps, such as needles and scalpels, should be placed in an approved sharps container in the operatory immediately after use, for later collection and disposal. (Figure 2) Other single-use dispos-able items should also be disposed of in the operatory.

Figure 2.

Proper techniques and sequencing of procedures

Cleaning Prior to Disinfection or Sterilization Cleaning to remove all debris is the essential first step in proper disinfection or sterilization. The presence of visible

or non-visible debris or organic substances may interfere with disinfection and sterilization. This concept applies to hand hygiene, environmental asepsis, and reprocessing re-usable instruments and items.

Cleaning and Sanitizing HandsThe CDC recommends a combined regimen of both hand-washing to clean hands and use of waterless hand sanitizers to kill organisms throughout the day. Handwashing with soap and water removes organisms and physical matter from hands, and may also kill organisms if antimicrobial soaps are used. If hands are visibly soiled, handwashing is always re-quired. Waterless hand sanitizers are poor cleaners but excel-lent antiseptics, and have been found to be significantly more effective than handwashing with antiseptic soap or plain soap at killing organisms.8,9 For surgical procedures, antimicrobial soap or an alcohol-based hand-rub with substantivity is re-quired10 — this will reduce hand flora and provide a residual antimicrobial effect under gloves, thus reducing bacterial re-growth. (Figure 3) Wearing gloves does not nullify the need for hand hygiene — gloves may be compromised or may have undetected defects that allow hand contamination. Hand hygiene is necessary prior to donning gloves, and hands must also be decontaminated after glove removal to remove patho-gens and to reduce the flora that may have multiplied in the warm, moist environment under gloves.

Wearing Personal Barriers

GlovesSingle-use gloves are vital elements of infection control programs. While they are not 100% reliable, they are es-sential barriers to protect patients and DHCPs. Aseptic

Figure 3. Hand hygiene

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technique must be observed; gloves must be removed when compromised, and after each patient, and hand hygiene performed immediately after removing gloves. Fresh gloves from the end of an open box in the operatory have been found to be contaminated with microorganisms prior to use11; therefore, gloves should ideally be stored in a closed container prior to use. Sharp-edged jewelry, and long or ragged fingernails are contraindicated as they may harbor organisms, tear and compromise gloves, as well as make gloves difficult to don.

Instrument ProcessingInstrument cleaning can be achieved by using enzymatic solutions and ultrasonic cleaning, by using instrument washers/disinfectors, or by hand scrubbing. Closed-cassette systems involve the use of operatory cassettes as trays that can be closed and locked after use and prior to cleaning, and can also be placed in a mechani-cal instrument cleaner prior to being sterilized. (Figure 4) This automates the process and minimizes the risk of personal injury.

Figure 4.

Hand scrubbing heavily contaminated instruments is unwise. If hand scrubbing must be performed, it should

be carried out wearing heavy-duty utility gloves to reduce the risk of puncture (masks, protective eyewear, and gowns should also be worn), scrubbing one instrument at a time, low down in the sink to minimize the risk of injury.12 Hand scrubbing after instruments have been treated with enzymatic cleaner (Figure 5) and/or ultra-sonic cleaning is safer, as the organic matter and most of the debris have already been removed.

Figure 5.

Eyewear, Masks and GownsProtective eyewear should be lightweight, clear, and dis-tortion-free. Protective eyewear and face shields should be washed and disinfected between patients, following the manufacturer’s instructions. Surgical masks should be worn for all dental procedures and should ideally be stored in a protected container to prevent contamination prior to use. If a mask becomes damaged or damp during a procedure, it should be changed out for a new mask. Clinical uniforms should protect all personal clothing and exposed skin, including the arms. If soiled, a clean gown should be donned. Single-use disposable gowns and shoe/foot shields are also available.

Gloves and masks should ideally be stored in a closed container prior to use.

Appropriate Product Selection and Use Infection control products should be selected based on the anticipated level of contamination exposure and the type of procedure being performed. Consult manufactur-ers to understand the uses and limitations of all infection control products, and communicate that information to all DHCPs.

Hand HygieneHand hygiene compliance is affected by perceptions that there is a low risk of cross-infection and that gloves are enough; compliance is also affected by perceived time

For handwashing:

1. Wet hands with water.

2. Apply soap.

3. Lather for at least 15 seconds.

4. Thoroughly rinse with water, and dry hands using disposable towels.

Plain soap and water effectively clean hands; they do not destroy pathogens.

For alcohol-based hand-rubs or solutions:

Follow the manufacturer’s recommendations for application and length of use.

Alcohol-based products destroy pathogens; they do not effectively clean hands.

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pressures and by irritated and dry skin.13 Non-compli-ance is a large contributing factor to disease outbreaks.14 Hand hygiene must be practical, routine, non-irritating and convenient.

Liquid- or foam-dispensed soaps in closed containers offer convenience and a reduced likelihood of contami-nation; however, they should not be topped-off, as this increases the risk of contamination. Bar soaps are exposed to microbial contaminants and are therefore less suitable; in public settings, these have been found to be a potential source of cross-infection.15 Available antimicrobial soaps include VioNex® Antimicrobial Liquid Soap (Kerr Total-Care™), which contains chloroxylenol, skin conditioners and emollients; Sani-Sept® (Crosstex), which contains 0.3% triclosan, aloe vera and vitamin E; and Hibiclens® (GC America) which contains chlorhexidine.

Foam-dispensed, closed-container soaps offer superior coverage using the minimum amount of product, reduc-ing the potential for skin reactions. (Figure 6) Antimicro-bial soaps are available with chloroxylenol, chlorhexidine gluconate, quaternary ammonium, povidone-iodine, hexachlorophene, or triclosan. Note that povidone-iodine is most commonly associated with allergic reactions; hexachlorophene is contraindicated in pregnant women and on denuded skin; and the effectiveness of quaternary ammonium products is impacted by exposure to organic materials. Chloroxylenol, chlorhexidine gluconate, and triclosan are well-tolerated, effective skin antimicrobials that are minimally affected by the presence of organic matter. Antimicrobial Foaming Soaps include VioN-exus™ (Kerr TotalCare) and Alcare (Vestal). The routine use of hand lotions containing emollients helps reduce irritation and drying of skin. Petroleum- and mineral oil-based emollients are unsuitable in lotions and alcohol-based hand sanitizers, as they affect glove integrity.

Foam-dispensed, closed-container soaps offer superior coverage using the minimum amount of

product, reducing the potential for skin reactions.

Alcohol-based solutions, gels, and towelettes are increasingly available to the public. For maximum ef-fectiveness balanced with skin protection and glove com-patibility, only medical-quality, FDA- or EPA-approved hand sanitizers should be used. Alcohol-based hand-rubs have been found to be more cost-effective and less time-consuming than handwashing.16 Concentrations should be 60% to 95%; ethanol-based products are more effective against viruses than isopropanol-based products (which are also more drying to skin). Dispensers or towelettes of-fer convenience and ease-of-use without requiring a sink. Many waterless sanitizers contain only alcohol as the active ingredient and are recommended for non-surgical

hand antisepsis. An example is Sani-Tyze (Crosstex), with aloe- and water-based emollients. Available prod-ucts containing both alcohol and an antimicrobial agent required for surgical alcohol-based hand products include VioNexus No Rinse Spray Antiseptic Handwash, which contains 66% ethanol, 0.10% benzalkonium chloride, and emollients; VioNex Towelette; VioNex® No-Rinse Gel Antiseptic Handwash (Kerr TotalCare), formulated with chloroxylenol, cleansers, and skin conditioners; and Sani-Dex (PDI). Since waterless sanitizers are to be used on “clean” hands, non-powdered gloves are recommended. The emollients in these products make donning gloves so easy that powder is not necessary.

Gloves, Eyewear and MasksGlove selection must consider the need for sterility, length of the procedure, chemical exposure, fit, latex and manufacturing allergies (alternatives to latex include nitrile and polychloroprene; nitrile provides superior chemical resistance). Eye shields must provide wrap-around protection to avoid exposure from the sides of the eyes. Prescription glasses typically do not wrap around the sides of the eyes and therefore provide insufficient barrier protection; if these are used, side shields should be fitted over the legs of the eyeglasses, or an eyeshield or a full face shield should be used over them. A full face shield such as Googles™ (Kerr TotalCare) protects the whole face and can be worn over eyeglasses and loupes. (Figure 7)

Key selection criteria for masks include the fit, fluid resistance, and filtration value (based on the size and per-centage of particles present — particle filtration efficiency). (Figure 8) Regular molded and tie-on masks have been found in one study to be only 85% to 86% effective, com-pared with 95% to 96% efficacy for a personal respirator that filters out particulate matter.17 Masks should provide American Societty for Testing Materials (ASTM) low-, moderate-, or high-barrier protection, as appropriate to the exposure risk of an activity. High-barrier protection masks

Figure 6.

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should be available for procedures that can result in higher levels of moisture and/or dust exposure, and moderate- and low-barrier protection masks should be available for lower-exposure procedures. For easy selection, Patterson masks are named according to ASTM level of protection. Crosstex clearly communicates the level of protection of their masks on the boxes, and the company offers train-ing in selection. N95 National Institute of Occupational Safety and Health (NIOSH) respirators provide respira-tory protection above that required for daily use and are recommended for transmission-based precautions, such as exposure to influenza.

Figure 7.

Figure 8.

Environmental (surface) barriersFitted, plastic, single-use disposable barriers are easy and quick to apply and remove, and are more likely to remain in position than plastic sheets or drapes. Fitted plastic barriers are available as slip-over sleeves for chairs, head-rests, lights, light-curing units, digital X-ray sensors, air-water syringe handles, impression guns, dental waterline units, and X-ray units. (Figure 9) For other items, im-permeable plastic wrap can be used. Computer keyboards have also been found to be a source of pathogenic bacteria in healthcare settings,18 suggesting that computer key-

boards in the clinical setting should also receive the same impermeable wrap.

Figure 9.

Disposable and Single-use Items Single-use disposable items include suction tips, saliva ejectors, X-ray holders, as well as trap filters for evacu-ation units and bite-blocks for panoramic radiographs. (Figure 10)

Figure 10.

Air-water syringe tips are an example of successful replacement of re-usable items by disposable products. Cleaning non-disposable metal air-water syringe tips is difficult and time-consuming due to their narrow lu-mens. The problem is compounded by the retraction of materials into the lumen. To break the chain of infection, disposable air-water syringes are a recommended alterna-tive. They are compatible with standard non-disposable fittings, are cost-effective, and are made of plastic with or without a metal tip insert to the handle of the syringe. (Figure 11) Other variants include plastic syringes with rubber O-ring seals and push-button converters for quick, user-friendly, tip changing (Seal-Tight® Dispos-able Air-Water Syringe Tips, Kerr TotalCare). In addi-tion to single-use disposable accessories and instruments, unit-dose products help reduce the risk of microbial con-tamination when handled aseptically, saving both time and money.

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Figure 11.

Surface Cleaners and Disinfectants: Product SelectionThe following factors should be considered:• The product’s ability to serve as both a high-perform-

ing cleaner and a disinfectant, reducing inventory requirements and making compliance easier (Products with high alcohol content are effective at disinfecting but poor at cleaning, requiring the use of a separate compatible product for cleaning.

• Choice of pre-mixed product or product that must be mixed (consider time, risk of spillage or mistakes in mix-ing, and product shelf-life after being opened or mixed).

• TB kill time choosing a product that takes less time to kill TB, the most resistant organism, reduces the time the product must remain on the surface, which in turn reduces costs associated with room turnaround time.

• Choice of aerosol, pump, or spray applicators (consider over-spray and aerosolization of chemicals).

• Propensity to stain, corrode, or rust materials.• Toxicity (such as likelihood of inhalation problems

or allergies).• Vehicle (whether the product is available as a solution,

spray, foam, and/or wipes).

Surface cleaners and disinfectants include those avail-able containing quaternary ammonium, phenolics, hy-drogen peroxide, EGME, iodophor, or citric acid. Wipes, sprays (such as CaviCide®, Kerr TotalCare; Citrex® Hos-pital Spray Disinfectant, Caltech), and foams typically use less volume of product than solutions do. (Figure 12) This reduces exposure to chemicals. Available wipes include CaviWipes™ (Kerr TotalCare), Sporicidin®, Asepti-wipe (Ecolab) and Clorox wipes (Bosworth). Wipes use the least product, are quick to use, and are less likely to cause aerosolization, splatter, or dripping of the product. A typical protocol for a pre-impregnated wipe cleaner and disinfectant such as CaviWipes or Patterson PDCare® wipes would be as follows:1. Clean the surface by wiping.2. Discard the used wipe.3. Select a new pre-impregnated towelette, and wipe

the surface.4. Leave the surface undisturbed for the length of time

of the TB kill (five minutes for CaviWipes).

If unsure about the toxicity, handling, or surface ef-fects of a surface cleaner or disinfectant, the manufacturer should be contacted for more information prior to use.

Choosing a product with a shorter TB kill time reduces the time the product must remain on the

surface, and thereby reduces associated costs.

Figure 12.

Instrument Sterilization, Disinfection, and Pre-cleaningEnzymatic foam cleaners speed up cleaning and debris re-moval. The foam is sprayed on the instruments and tray prior to taking them to the instrument processing area. This starts the dissolution of organic matter and the loosening of gross debris, without giving these contaminants a chance to dry on the instruments. Enzymatic foams currently available in-clude EmPower™ Foam (Kerr TotalCare), Zymex® (Sultan), ProEZ® Foam (Certol) and Prezyme® (L&R). Pre-cleaning the instruments with enzymatic foam to remove debris in-creases the lifespan of ultrasonic solutions, which should be changed at least once a day (and more often if heavily-con-taminated instruments are placed in it). Some enzymatics, such as EmPower, can be used as a pre-soak solution, an ul-trasonic solution, and an evacuation solution. Ultrasonic so-lutions should be used in accordance with the manufacturer’s recommendations. In selecting these solutions, consider both cleaning ability and the potential for damage to instruments exposed to them. Solutions containing enzymes, detergents, and rust inhibitors are particularly effective and help prevent rust and corrosion damage to instruments. After cleaning, instruments and trays must be dried and appropriately pack-aged prior to sterilization. Instrument sterilization can be performed using an FDA-cleared steam autoclave, a dry-heat sterilizer, a forced-air convection sterilizer, or an unsaturated chemical vapor sterilizer.19

If the instrument is heat-sensitive and is semi-critical or non-critical, it can be sterilized by immersing in a high-level disinfectant/sterilant such as ProCide-D Plus® (Kerr Total-Care), which contains 3.4% buffered glutaraldehyde solution and can be used to sterilize immersible instruments by soak-ing them for 10 hours at 77º F. (Figure 13) Other high-level disinfectant/sterilants include Omnicide® (Cardinal) and Sporicidin. Surface (intermediate-level) disinfectants may not be used in place of a high-level disinfectant/sterilant; this would result in inadequate infection control, would not meet EPA requirements, and would be a violation of federal law. Heat sterilizable or disposable items are preferred. Some manufacturers provide excellent training resources for their products based on recommended safe practices.

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Figure 13.

SummarySuccessful infection control breaks the “chain of infection” by applying the concept of cleaning prior to disinfection or sterilization and by following recommended steps in the logi-cal and appropriate sequences. This strategy applies to hand hygiene, instrument re-processing, environmental asepsis, and use of personal protective barriers, and should be central to establishing office protocol and safety product selection. New single-use disposable items, as well as quicker and safer chemical and physical treatments, have become key compo-nents of an appropriate infection control program.

References1 Bentley CD, Burkhart NW, Crawford JJ. Evaluating spatter and

aerosol contamination during dental procedures. J Am Dent Assoc. 1994;125(5):579–584.

2 Morbidity and Mortality Weekly Report. Recommendations and Reports. Guidelines for Infection Control in Dental Health-Care Settings — 2003; 52(No.RR-17).

3 Huber MA, Holton RH, Terezhalmy GT. Cost analysis of hand hygiene using antimicrobial soap and water versus an alcohol-based hand rub. J Contemp Dent Pract. 2006;7(2):37–45.

4 Lonnroth EC, Shahnavaz H. Adverse health reactions in skin, eyes, and respiratory tract among dental personnel in Sweden. Swed Dent J. 1998;22(1–2):33–45.

5 Kurita H, Kurashina K, Honda T. Nosocomial transmission of methicillin-resistant Staphylococcus aureus via the surfaces of the dental operatory. Br Dent J. 2006 Sep 9;201(5):297–300.

6 Redd JT, Baumbach J, Kohn W, Nainan O, Khristova M, Williams I. Patient-to-patient transmission of hepatitis B virus associated with oral surgery. J Infect Dis. 2007;195(9):1311–1314.

7 CDC. Recommended infection-control practices for dentistry, 1993. MMWR. 1993;42(No. RR-8).

8 Girou E, Loyeau S, Legrand P, Oppein F, Brun-Buisson C. Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ. 2002;325(7360):362.

9 Kac G, Podglajen I, Gueneret M, Vaupre S, Bissery A, Meyer G. Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study. J Hosp Infect. 2005 May;60(1):32–39.

10 Morbidity and Mortality Weekly Report. Recommendations and Reports. Guidelines for Infection Control in Dental Health-Care Settings — 2003;52(RR-17).

11 Luckey JB, Barfield RD, Eleazer PD. Bacterial count comparisons on examination gloves from freshly opened boxes versus nearly empty boxes and from examination gloves before treatment versus after dental dam isolation. J Endod. 2006;32(7):646–648.

12 www.osha.gov/SLTC/dentistry/index.html. Accessed 2007.13 Huber MA, Holton RH, Terezhalmy GT. Cost analysis of hand

hygiene using antimicrobial soap and water versus an alcohol-based hand rub. J Contemp Dent Pract. 2006;7(2):37–45.

14 CDC. Guideline for hand hygiene in health-care settings:

recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16).

15 Kabara JJ, Brady MB. Contamination of bar soaps under “in-use” conditions. J Environ Pathol Toxicol Oncol. 1984;5:1–14.

16 Huber MA, Holton RH, Terezhalmy GT. Cost analysis of hand hygiene using antimicrobial soap and water versus an alcohol-based hand rub. J Contemp Dent Pract. 2006;7(2):37–45.

17 Checchi L, Montevecchi M, Moreschi A, Graziosi F, Taddei P, Violante FS. Efficacy of three face masks in preventing inhalation of airborne contaminants in dental practice. J Am Dent Assoc. 2005;136(7):877–882.

18 Bures S, Fishbain JT, Uyehara CF, Parker JM, Berg BW. Computer keyboards and faucet handles as reservoirs of nosocomial pathogens in the intensive care unit. Am J Infect Control. 2000;28(6):465–471.

19 Miller CH, Palenik CJ. Sterilization, disinfection, and asepsis in dentistry. In: Block SS, ed. Disinfection, Sterilization, and Preservation. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins. 2001:1053.

Author Profile

Nancy Andrews, RDH, BSMs. Andrews is a nationally recognized speaker, author and educational consultant and has written more than 80 peer-reviewed articles. She received her B.S.D.H. from University of Southern California, where she was later a

clinical instructor. Ms. Andrews practiced clinical Dental Hygiene for 20 years. She has consulted with individual and large dental facilities, dental laboratories and dental corporations on clinical safety and OSHA compliance. She has given seminars nationally and internationally on top-ics including Diseases and Infection Prevention, Biofilms, and Dental Waterlines and also participated in the drafting of the OSAP Position Paper on Dental Unit Waterlines. Ms. Andrews is an active member of OSAP, ADHA, and CDHA. She can be reached at Nancyandrewsrdh.com.

DisclaimerThe author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Reader FeedbackWe encourage your comments on this or any ADTS course. For your convenience, an online feedback form is available at www.ineedce.com.

Non-Educational ContentTotalCare, a division of Kerr, offers an extensive array of infection control products for the dental industry. TotalCare features the brand names Pinnacle and Metrex. Pinnacle products include barrier protection accessories and single-use disposables for the dental operatory. Metrex infection control products serve to protect staff and patients with products for surface disinfection, instrument sterilization and hand care. All TotalCare products are available from authorized dealers.

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Questions

1. The pathway of disease transmission is referred to as the _______________.a. chain of affectionb. chain of infectionc. infection linkages d. All of the above.

2. Disease transmission requires__________.a. a susceptible host and entry portalb. a source of microbesc. a method of transmission and exposured. All of the above.

3. Hand contact with contaminated surfaces is an example of _______________.a. indirect transmissionb. direct transmissionc. contamination preventiond. a and b.

4. Transient flora is more commonly associated with healthcare-related infections than resident flora.a. True.b. False.

5. The routine use of personal barriers by DHCPs _______________.a. is now “standard practice”b. is only required in high-risk situationsc. has been very successful in reducing DHCP

exposure to infectionsd. a and c.

6. Impermeable single-use environmental (surface) barriers _______________.a. result in less time being spent on

environmental asepsisb. result in more reliable asepsisc. provide a visual image for patients that

communicates asepsisd. All of the above.

7. Cultures of operatory surfaces have yielded organisms including methicillin-resistant Staphylococcus aureus.a. True.b. False.

8. _______________ may interfere with thorough disinfection and sterilization.a. The presence of visible debrisb. The presence of invisible debrisc. The presence of organic substancesd. All of the above.

9. Instrument cleaning, the essential first step in instrument processing can be carried out with _______________.a. ultrasonic cleanersb. enzymatic solutions c. instrument washersd. All of the above.

10. Hand scrubbing instruments _______________.a. should only be performed wearing heavy-duty

utility glovesb. can be performed wearing light surgical glovesc. is safer if the instruments have been

pre-treated with an enzymatic cleaners or cleaned ultrasonically

d. a and c.

11. An alcohol-based hand-rub is acceptable as the sole hand hygiene procedure _______________. a. for non-surgical procedures if hands are

visibly soiled b. for surgical proceduresc. for non-surgical procedures if hands are

not visibly soiledd. b and c.

12. Handwashing after glove removal is important because ____________.a. pathogens may have gained entry through defects

in the gloves during the procedureb. flora may have multiplied in the warm, moist

environment under the glovesc. hands will feel dry after removing glovesd. a and b.

13. Sterile surgical gloves _______________.a. are required for all proceduresb. are required for surgical proceduresc. are required for instrument cleaning d. All of the above.

14. Hand hygiene compliance is affected by _______________.a. the perception that there is a low risk

of cross-infectionb. the perception that gloves are enoughc. irritated and dry skin d. All of the above.

15. With respect to liquid and foam soaps dispensed from closed containers, _______________.a. the soap dispenser containers can be topped-offb. they are more convenient than bar soaps and

reduce the risk of contaminationc. they do not contain emollients d. All of the above.

16. Foam-dispensed soaps offer superior coverage using the minimum amount of product.a. True.b. False.

17. Active ingredients used in antimicrobial soaps include _______________.a. chloroxylenol, chlorhexidine gluconate, triclosan,

povidone-iodine b. triglycerides, iodophones and chlorhexidinec. quaternary ammonium, hexachlorophene d. a and c.

18. Of the antimicrobials that can be included in soaps, ____________ is most commonly associated with allergic reactions and ___________ is contraindi-cated in pregnant women.a. povidone-iodine, hexachloropheneb. povidone-iodine, chloroxylenolc. chlorhexidine gluconate, quaternary ammoniumd. None of the above.

19. Alcohol-based hand-rubs ___________ .a. offer convenienceb. do not require a sinkc. are more cost-effective and less time-consuming

than handwashingd. All of the above.

20. Eyewear used for protection should be _______________ . a. lightweightb. clearc. able to wrap-around the eyes to offer

full protectiond. All of the above.

21. Non-disposable metal air-water syringe tips _______________.a. are difficult and time-consuming to cleanb. are required and there is no suitable substitutec. can be substituted by plastic single-use disposable

air-water syringe tipsd. a and c.

22. In considering surface cleaners, impor-tant factors include _______________.a. the ability of the product to serve as both a cleaner

and disinfectantb. the TB kill time c. the ability of the solution to dry rapidlyd. a and b.

23. Compared to surface cleaning solutions, wipes_______________ .a. use the least product, are quick to use and

less likely to result in dripping of the productb. use more product to ensure better

surface coveragec. use the same amount of product as solutions

but are significantly more effective at cleaningd. All of the above.

24. The same wipe can be used for cleaning and disinfecting, without a fresh one being required.a. True.b. False.

25. Enzymatic foam cleaners ____________.a. speed up bacterial resistanceb. speed up cleaning and debris removalc. should be sprayed on instruments only in the

instrument processing aread. b and c.

26. Pre-cleaning instruments with enzymatic foam prior to ultrasonic cleaning _______________.a. increases the lifespan of ultrasonic solutionsb. decreases the likelihood of corrosion of the

ultrasonic bathc. increases the concentration of ultrasonic cleaning

solution requiredd. All of the above.

27. Critical instruments that penetrate the mucosa _______________.a. can be single-use disposableb. can be re-usable and heat-sensitivec. can be re-usable and heat-resistantd. a and c.

28. Re-usable critical instruments must be cleaned and then heat-sterilized.a. True.b. False.

29. Semi-critical instruments, if heat- sensitive, can be chemical-sterilized using glutaraldehyde. a. True.b. False.

30. For chemical-sterilization of instruments,_____________.a. use of intermediate-level disinfectant

is acceptableb. only high-level disinfectants can be usedc. use of intermediate-level disinfectant would meet

EPA guidelinesd. All of the above.

www.ineedce.com 11

Name:

Title: Specialty:

Address: E-mail:

City: State: ZIP:

Telephone: Home ( ) Office ( )

Instructions to obtain dental continuing education credits: 1) Complete all information above. 2) Complete answer sheets in either pen or pencil. 3) Mark only one answer for each question. 4) Successful completion of this course will earn you 4 CEUs. 5) A blank duplicate answer sheet may be copied for additional course participants.

Mail completed answer sheet toAcademy of Dental Therapeutics and Stomatology

P.O. Box 116, Chesterland, OH 44026(216) 398-7822

For IMMEDIATE results, go to www.ineedce.com and click on the button “ENTER Answers Online.”Answer sheets can be faxed with credit card payment to (216) 255-6619, (440) 845-3447, or (216) 398-7922.

❏ Payment of $59.00 is enclosed. (Checks and credit cards are accepted.)

If paying by credit card, please complete the following: ❏ MasterCard ❏ Visa ❏ AmEx ❏ Discover

Acct. Number: _______________________________

Exp. Date: _____________________

Course EvaluationPlease evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

1. How would you rate the objectives and educational methods?

5 4 3 2 1 0

2. To what extent were the course objectives accomplished?

5 4 3 2 1 0

3. Please rate the course content.

5 4 3 2 1 0

4. Please rate the instructor’s effectiveness.

5 4 3 2 1 0

5. Was the overall administration of the course effective?

5 4 3 2 1 0

6. How do you rate the author’s grasp of the topic?

5 4 3 2 1 0

7. Do you feel that the references were adequate?

Yes No

8. Do you feel that the educational objectives were met?

Yes No

9. If any of the continuing education questions were unclear or ambiguous, please list them. __________________________________________________

10. Was there any subject matter you found confusing? Please describe. __________________________________________________

11. Would you participate in a program similar to this one in the future on a different topic? Yes No

12. What additional continuing dental education topics would you like to see? __________________________________________________

ANSWER SHEET

Breaking the Chain of Infection: Practical and Effective Infection Control

AUTHOR DISCLAIMERThe author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

INSTRUCTIONSEach question should have only one answer. Grading of this examination is done manually. Participants will receive verification in the mail within three to four weeks after taking an examination.

SPONSOR/PROVIDERThis course was made possible through an unrestricted educational grant from Kerr TotalCare®. No manufacturer or 3rd party has had any input into the development of course content. All content has been derived from the references listed and the opinions of clinicians. Please direct all questions pertaining to the ADTS or the administration of this course to the program director: P.O. Box 116, Chesterland, OH 44026, or e-mail aeagle@ineedce.com.

PARTICIPANT FEEDBACKQuestions can be e-mailed to aeagle@ineedce.com or faxed to (216) 255-6619, (440) 845-3447, or (216) 398-7922.

COURSE CREDITS/COSTAll participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive verification of 4 CEUs. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. For current terms of acceptance, please contact the ADTS. “DANB Approval” indicates that a continuing education course appears to meet certain specifications as described in the DANB Recertification Guidelines. DANB does not, however, endorse or recommend any particular continuing education course and is not responsible for the quality of any course content. Participants are urged to contact their state dental boards for continuing education requirements. The cost of this course is $59.00.

EDUCATIONAL DISCLAIMERThe information presented here is for educational purposes only. It may not be possible to present all information required to utilize or apply this knowledge to practice. It is therefore recommended that additional knowledge be sought before attempting a new procedure or incorporating a new technique or therapy. The opinions of efficacy or the perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the courses and do not necessarily reflect those of the ADTS.

RECORD KEEPINGThe ADTS maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which lists all credits earned to date, will be generated and mailed to you within five business days of receipt of your request.

CANCELLATION/REFUND POLICYAny participant who is not 100% satisfied with this course can request a full refund by contacting the Academy of Dental Therapeutics and Stomatology in writing.

COURSE EVALUATIONWe encourage participant feedback pertaining to all courses. Please be sure to complete the survey included within the answer sheet. © 2007 by the Academy of Dental Therapeutics and Stomatology

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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AGD Code 148