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## Complete Summary

#### GUIDELINE TITLE

Guidelines for infection control in dental health-care settings-2003.

#### BIBLIOGRAPHIC SOURCE(S)

Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM.
Guidelines for infection control in dental health-care settings\--2003.
MMWR Recomm Rep 2003 Dec 19;52(RR-17):1-61. \[471 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14685139)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Infections associated with dental care

#### GUIDELINE CATEGORY

Prevention

#### CLINICAL SPECIALTY

Dentistry\
Infectious Diseases

#### INTENDED USERS

Allied Health Personnel\
Dentists

#### GUIDELINE OBJECTIVE(S)

To provide appropriate recommendations for infection control in dental
settings

#### TARGET POPULATION

-   Patients receiving dental care

-   Dental health-care personnel (DHCP) providing dental care

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Written infection control program

2.  Education and training

3.  Immunizations

4.  Universal precautions

5.  Engineering and work-practice controls

6.  Post-exposure management and prophylaxis

7.  Hand hygiene

8.  Personnel protective equipment (PPE), such as masks, protective
    eyewear, face shields, protective clothing, and gloves

9.  Sterilization and disinfection of patient-care items

10. Environmental infection control practices, considering items such as
    cleaning products, surfaces to be cleaned, and medical waste

11. Dental unit waterlines, biofilm, and water quality monitoring

12. Routine evaluation of infection-control program

#### MAJOR OUTCOMES CONSIDERED

-   Risk of exposure

-   Effectiveness of interventions used to prevent disease transmission

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The guidelines were developed by Centers for Disease Control and
Prevention (CDC) staff members in collaboration with other authorities
on infection control. Existing guidelines and published research
pertinent to dental infection-control principles and practices were
reviewed. Wherever possible, recommendations are based on data from
well-designed scientific studies. In the absence of scientific evidence,
certain recommendations are based on strong theoretical rationale,
suggestive evidence, or opinions of respected authorities based on
clinical experience, descriptive studies, or committee reports. In
addition, some recommendations are derived from federal regulations. No
recommendations are offered for practices for which insufficient
scientific evidence or lack of consensus supporting their effectiveness
exists.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Rankings are based on the system used by Centers for Disease Control and
Prevention (CDC) and the Healthcare Infection Control Practices Advisory
Committee (HICPAC) to categorize recommendations.

**Category IA**. Strongly recommended for implementation and strongly
supported by well-designed experimental, clinical, or epidemiologic
studies

**Category IB**. Strongly recommended for implementation and supported
by experimental, clinical, or epidemiologic studies and a strong
theoretical rationale

**Category IC**. Required for implementation as mandated by federal or
state regulation or standard. When IC is used, a second rating can be
included to provide the basis of existing scientific data, theoretical
rationale, and applicability. Because of state differences, the reader
should not assume that the absence of a IC implies the absence of state
regulations.

**Category II**. Suggested for implementation and supported by
suggestive clinical or epidemiologic studies or a theoretical rationale

**Unresolved issue**. No recommendation. Insufficient evidence or no
consensus regarding efficacy exists

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Draft documents were reviewed by other federal agencies and professional
organizations from the fields of dental health care, public health, and
hospital epidemiology and infection control. A *Federal Register* notice
elicited public comments that were considered in the decision-making
process.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of recommendations (IA, IB, IC, II, Unresolved issues) are
defined at the end of the \"Major Recommendations\" field.

I.  **Personnel Health Elements of an Infection-Control Program**

    A.  **General Recommendations**

        1.  Develop a written health program for dental health-care
            personnel (DHCP) that includes policies, procedures, and
            guidelines for education and training; immunizations;
            exposure prevention and postexposure management; medical
            conditions, work-related illness, and associated work
            restrictions; contact dermatitis and latex hypersensitivity;
            and maintenance of records, data management, and
            confidentiality **(IB)** (Bolyard et al., 1998; Gershon et
            al., 2000; CDC, \"Immunization of health-care workers,\"
            1997; DeCastro et al., 1999; Herwaldt et al., 1997).

        2.  Establish referral arrangements with qualified health-care
            professionals to ensure prompt and appropriate provision of
            preventive services, occupationally related medical
            services, and postexposure management with medical follow-up
            **(IB, IC)** (Bolyard et al., 1998; US Department of Labor,
            Occupational Safety and Health Administration, 29 CFR Part
            1910.1030, 2001; \"Updated U.S. Public Health Service
            guidelines,\" 2001; Herwaldt et al., 1997).

    B.  **Education and Training**

        1.  Provide DHCP 1) on initial employment, 2) when new tasks or
            procedures affect the employee´s occupational exposure,
            and 3) at a minimum, annually, with education and training
            regarding occupational exposure to potentially infectious
            agents and infection-control procedures/protocols
            appropriate for and specific to their assigned duties **(IB,
            IC)** (Bolyard et al. 1998; Garner, 1996; US Department of
            Labor, Occupational Safety and Health Administration, 29 CFR
            Part 1910.1030, 2001; US Department of Labor, Occupational
            Safety and Health Administration, \"OSHA instruction,\"
            2001; Gershon et al., 2000; \"Updated U.S. Public Health
            Service guidelines,\" 2001; Herwaldt et al., 1997).

        2.  Provide educational information appropriate in content and
            vocabulary to the educational level, literacy, and language
            of DHCP **(IB, IC)** (Bolyard et al. 1998; US Department of
            Labor, Occupational Safety and Health Administration, 29 CFR
            Part 1910.1030, 2001).

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    A.  **Immunization Programs**

        1.  Develop a written comprehensive policy regarding immunizing
            DHCP, including a list of all required and recommended
            immunizations **(IB)** (Bolyard et al. 1998; CDC,
            \"Immunization of health-care workers,\" 1997; DeCastro et
            al., 1999).

        2.  Refer DHCP to a prearranged qualified healthcare
            professional or to their own health-care professional to
            receive all appropriate immunizations based on the latest
            recommendations as well as their medical history and risk
            for occupational exposure **(IB)** (Bolyard et al. 1998;
            CDC, \"Immunization of health-care workers,\" 1997).

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    A.  **Exposure Prevention and Postexposure Management**

        1.  Develop a comprehensive postexposure management and medical
            follow-up program **(IB, IC**) (Bolyard et al. 1998; US
            Department of Labor, Occupational Safety and Health
            Administration, 29 CFR Part 1910.1030, 2001; US Department
            of Labor, Occupational Safety and Health Administration,
            \"OSHA instruction,\" 2001; \"Updated U.S. Public Health
            Service guidelines,\" 2001).

            a.  Include policies and procedures for prompt reporting,
                evaluation, counseling, treatment, and medical follow-up
                of occupational exposures.

            b.  Establish mechanisms for referral to a qualified
                health-care professional for medical evaluation and
                follow-up.

            c.  Conduct a baseline tuberculin skin test (TST),
                preferably by using a two-step test, for all DHCP who
                might have contact with persons with suspected or
                confirmed infectious tuberculosis (TB), regardless of
                the risk classification of the setting **(IB)**
                (\"Guidelines for preventing the transmission of
                Mycobacterium tuberculosis,\" 1994).

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    E.  **Medical Conditions, Work-Related Illness, and Work
        Restrictions**

        1.  Develop and have readily available to all DHCP comprehensive
            written policies regarding work restriction and exclusion
            that include a statement of authority defining who can
            implement such policies **(IB)** (Bolyard et al. 1998;
            Herwaldt et al., 1997).

        2.  Develop policies for work restriction and exclusion that
            encourage DHCP to seek appropriate preventive and curative
            care and report their illnesses, medical conditions, or
            treatments that can render them more susceptible to
            opportunistic infection or exposures; do not penalize DHCP
            with loss of wages, benefits, or job status **(IB)**
            (Bolyard et al. 1998; Herwaldt et al., 1997).

        3.  Develop policies and procedures for evaluation, diagnosis,
            and management of DHCP with suspected or known occupational
            contact dermatitis **(IB)** (CDC, National Institute for
            Occupational Safety and Health \[NIOSH\], 1997).

        4.  Seek definitive diagnosis by a qualified healthcare
            professional for any DHCP with suspected latex allergy to
            carefully determine its specific etiology and appropriate
            treatment as well as work restrictions and accommodations
            **(IB)** (CDC, NIOSH, 1997).

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    C.  **Records Maintenance, Data Management, and Confidentiality**

        1.  Establish and maintain confidential medical records (e.g.,
            immunization records and documentation of tests received as
            a result of occupational exposure) for all DHCP **(IB, IC)**
            (Bolyard et al., 1998; US Department of Labor, Occupational
            Safety and Health Administration, 29 CFR Part 1910.1030,
            2001).

        2.  Ensure that the practice complies with all applicable
            federal, state, and local laws regarding medical
            recordkeeping and confidentiality **(IC)** (US Department of
            Labor, Occupational Safety and Health Administration, 29 CFR
            Part 1910.1030, 2001; \"Standards for privacy,\" 2000).

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II. **Preventing Transmission of Bloodborne Pathogens**

    A.  **Hepatitis B Virus (HBV) Vaccination**

        1.  Offer the hepatitis B virus (HBV) vaccination series to all
            DHCP with potential occupational exposure to blood or other
            potentially infectious material **(IA, IC)** (\"Recommended
            infection-control,\" 1993; US Department of Labor,
            Occupational Safety and Health Administration, 29 CFR Part
            1910.1030, 2001; US Department of Labor, Occupational Safety
            and Health Administration, \"OSHA instruction,\" 2001;
            \"Updated U.S. Public Health Service guidelines,\" 2001).

        2.  Always follow U.S. Public Health Service/CDC recommendations
            for hepatitis B vaccination, serologic testing, follow-up,
            and booster dosing (**IA**, **IC**) (US Department of Labor,
            Occupational Safety and Health Administration, 29 CFR Part
            1910.1030, 2001; US Department of Labor, Occupational Safety
            and Health Administration, \"OSHA instruction,\" 2001;
            \"Updated U.S. Public Health Service guidelines,\" 2001).

        3.  Test DHCP for hepatitis B surface antibodies (anti-HBs) 1 to
            2 months after completion of the 3-dose vaccination series
            **(IA, IC)** (US Department of Labor, Occupational Safety
            and Health Administration, \"OSHA instruction,\" 2001;
            \"Updated U.S. Public Health Service guidelines,\" 2001).

        4.  DHCP should complete a second 3-dose vaccine series or be
            evaluated to determine if they are hepatitis B surface
            antigen (HBsAg)-positive if no antibody response occurs to
            the primary vaccine series **(IA, IC)** (US Department of
            Labor, Occupational Safety and Health Administration, \"OSHA
            instruction,\" 2001; \"Updated U.S. Public Health Service
            guidelines,\" 2001).

        5.  Retest for anti-HBs at the completion of the second vaccine
            series. If no response to the second 3-dose series occurs,
            nonresponders should be tested for HBsAg **(IC)** (US
            Department of Labor, Occupational Safety and Health
            Administration, \"OSHA instruction,\" 2001; \"Updated U.S.
            Public Health Service guidelines,\" 2001).

        6.  Counsel nonresponders to vaccination who are HBsAg-negative
            regarding their susceptibility to HBV infection and
            precautions to take **(IA, IC)** (US Department of Labor,
            Occupational Safety and Health Administration, \"OSHA
            instruction,\" 2001; \"Updated U.S. Public Health Service
            guidelines,\" 2001).

        7.  Provide employees appropriate education regarding the risks
            of HBV transmission and the availability of the vaccine.
            Employees who decline the vaccination should sign a
            declination form to be kept on file with the employer
            **(IC)** (US Department of Labor, Occupational Safety and
            Health Administration, 29 CFR Part 1910.1030, 2001).

    B.  **Preventing Exposures to Blood and Other Potentially Infectious
        Materials (OPIM)**

        1.  General recommendations

            a.  Use standard precautions (Occupational Safety and Health
                Administration´s \[OSHA´s\] blood-borne pathogen
                standard retains the term universal precautions) for all
                patient encounters **(IA, IC)** (Garner, 1996; US
                Department of Labor, Occupational Safety and Health
                Administration, 29 CFR Part 1910.1030, 2001; \"Updated
                U.S. Public Health Service guidelines,\" 2001;
                \"Recommendations for preventing transmission,\" 1991).

            b.  Consider sharp items (e.g., needles, scalers, burs, lab
                knives, and wires) that are contaminated with patient
                blood and saliva as potentially infective, and establish
                engineering controls and work practices to prevent
                injuries **(IB, IC)** (Greene, 1969; US Department of
                Labor, Occupational Safety and Health Administration, 29
                CFR Part 1910.1030, 2001; \"Recommendations for
                prevention of HIV,\" 1987).

            c.  Implement a written, comprehensive program designed to
                minimize and manage DHCP exposures to blood and body
                fluids **(IB, IC)**. (US Department of Labor,
                Occupational Safety and Health Administration, \"OSHA
                instruction,\" 2001; US Department of Labor,
                Occupational Safety and Health Administration, 29 CFR
                Part 1910.1030, 2001; \"Updated U.S. Public Health
                Service guidelines,\" 2001; CDC, NIOSH, 1999).

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        2.  Engineering and work-practice controls

            a.  Identify, evaluate, and select devices with engineered
                safety features at least annually and as they become
                available on the market (e.g., safer anesthetic
                syringes, blunt suture needle, retractable scalpel, or
                needleless intravenous \[IV\] systems) **(IC)** (US
                Department of Labor, Occupational Safety and Health
                Administration, 29 CFR Part 1910.1030, 2001; \"Framework
                for program evaluation,\" 1999; CDC, \"Evaluation of
                safety devices,\" 1997; CDC, \"Evaluation of blunt
                suture needles,\" 1997; Mendelson et al., 2003).

            b.  Place used disposable syringes and needles, scalpel
                blades, and other sharp items in appropriate
                puncture-resistant containers located as close as
                feasible to the area in which the items are used **(IA,
                IC)** (\"Recommended infection control,\" 1993;
                \"Update: universal precautions,\" 1988; US Department
                of Labor, Occupational Safety and Health Administration,
                29 CFR Part 1910.1030, 2001; \"Updated U.S. Public
                Health Service guidelines,\" 2001; \"Recommendations for
                prevention of HIV,\" 1987; CDC, NIOSH, 1998).

            c.  Do not recap used needles by using both hands or any
                other technique that involves directing the point of a
                needle toward any part of the body. Do not bend, break,
                or remove needles before disposal **(IA, IC)**
                (\"Recommended infection control,\" 1993; \"Update:
                Universal precautions,\" 1988; \"Guidelines for
                prevention of transmission,\" 1989; US Department of
                Labor, Occupational Safety and Health Administration, 29
                CFR Part 1910.1030, 2001; CDC, NIOSH, 1999;
                \"Recommendations for prevention of HIV,\" 1987).

            d.  Use either a one-handed scoop technique or a mechanical
                device designed for holding the needle cap when
                recapping needles (e.g., between multiple injections and
                before removing from a nondisposable aspirating syringe)
                **(IA, IC)** (\"Recommended infection control,\" 1993;
                \"Update: universal precautions,\" 1988; \"Guidelines
                for prevention of transmission,\" 1989; US Department of
                Labor, Occupational Safety and Health Administration, 29
                CFR Part 1910.1030, 2001; US Department of Labor,
                Occupational Safety and Health Administration, \"OSHA
                instruction,\" 2001; \"Recommendations for prevention of
                HIV,\" 1987).

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        1.  Postexposure management and prophylaxis

            a.  Follow CDC recommendations after percutaneous, mucous
                membrane, or nonintact skin exposure to blood or other
                potentially infectious material **(IA, IC)** (US
                Department of Labor, Occupational Safety and Health
                Administration, 29 CFR Part 1910.1030, 2001; US
                Department of Labor, Occupational Safety and Health
                Administration, \"OSHA instruction,\" 2001; \"Updated
                U.S. Public Health Service guidelines,\" 2001).

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III. **Hand Hygiene**

     A.  **General Considerations**

         1.  Perform hand hygiene with either a nonantimicrobial or an
             antimicrobial soap and water when hands are visibly dirty
             or contaminated with blood or other potentially infectious
             material. If hands are not visibly soiled, an alcohol-based
             hand rub can also be used. Follow the manufacturer´s
             instructions **(IA)** (Boyce & Pittet, 2002).

         2.  Indications for hand hygiene include

             a.  when hands are visibly soiled **(IA, IC)**

             b.  after barehanded touching of inanimate objects likely
                 to be contaminated by blood, saliva, or respiratory
                 secretions **(IA, IC)**

             c.  before and after treating each patient **(IB)**

             d.  before donning gloves **(IB)**

             e.  immediately after removing gloves **(IB, IC)**
                 (\"Update: Universal precautions,\" 1988; \"Guidelines
                 for prevention of transmission,\" 1989; Garner &
                 Favero, 1986; Garner, 1996; US Department of Labor,
                 Occupational Safety and Health Administration, 29 CFR
                 Part 1910.1030, 2001; \"Recommendations for prevention
                 of HIV,\" 1987; Steere & Mallison, 1975; Garner, 1986;
                 Association for Professionals in Infection Control and
                 Epidemiology \[APIC\], 1995; Boyce & Pittet, 2002;
                 Larson et al., 2000; Pittet et al., 2000; Doebbeling et
                 al., 1988).

         3.  For oral surgical procedures, perform surgical hand
             antisepsis before donning sterile surgeon´s gloves. Follow
             the manufacturer´s instructions by using either an
             antimicrobial soap and water, or soap and water followed by
             drying hands and application of an alcohol-based surgical
             handscrub product with persistent activity **(IB)**
             (Garner, 1986; APIC, 1995; Boyce & Pittet, 2002; Price,
             1938; Dewar & Gravens, 1973; Lowbury & Lilly, 1960; Rotter,
             1999; Widmer, 2000; Larson et al., 1990; Faoagali et al.,
             1995; Hobson et al., 1998; Mulbury et al., 2001).

         4.  Store liquid hand-care products in either disposable closed
             containers or closed containers that can be washed and
             dried before refilling. Do not add soap or lotion to (i.e.,
             top off) a partially empty dispenser **(IA)** (Garner &
             Favero, 1986; Steere & Mallison, 1975; APIC, 1995;
             Grohskopf et al., 2001; Archibald et al., 1997).

     B.  **Special Considerations for Hand Hygiene and Glove Use**

         1.  Use hand lotions to prevent skin dryness associated with
             hand washing **(IA)** (Berndt et al., 2000; McCormick,
             Buchman, & Maki, 2000).

         2.  Consider the compatibility of lotion and antiseptic
             products and the effect of petroleum or other oil
             emollients on the integrity of gloves during product
             selection and glove use **(IB)** (\"Recommended infection
             control,\" 1993; US Department of Labor, Occupational
             Safety and Health Administration, \"OSHA instruction,\"
             2001; APIC, 1995; Larson et al., 1993).

         3.  Keep fingernails short with smooth, filed edges to allow
             thorough cleaning and prevent glove tears **(II)** (APIC,
             1995; Boyce & Pittet, 2002; McGinley, Larson, & Leyden,
             1988).

         4.  Do not wear artificial fingernails or extenders when having
             direct contact with patients at high risk (e.g., those in
             intensive care units or operating rooms) **(IA)** (Boyce &
             Pittet, 2002; Pottinger, Burns, & Manske, 1989; McNeil et
             al., 2001; Rubin, 1988; Hedderwick et al., 2000).

         5.  Use of artificial fingernails is usually not recommended
             **(II)** (Pottinger, Burns, & Manske, 1989; McNeil et al.,
             2001; Rubin, 1988; Hedderwick et al., 2000).

         6.  Do not wear hand or nail jewelry if it makes donning gloves
             more difficult or compromises the fit and integrity of the
             glove **(II)** (Boyce & Pittet, 2002; Larson, 1989; Field
             et al., 1996).

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IV. **Personal Protection Equipment (PPE)**

    A.  **Masks, Protective Eyewear, and Face Shields**

        1.  Wear a surgical mask and eye protection with solid side
            shields or a face shield to protect mucous membranes of the
            eyes, nose, and mouth during procedures likely to generate
            splashing or spattering of blood or other body fluids **(IB,
            IC)** (\"Recommended infection-control practices,\" 1986;
            \"Recommended infection control,\" 1993; \"Update: universal
            precautions,\" 1988; \"Guidelines for prevention of
            transmission,\" 1989; Garner, 1996; US Department of Labor,
            Occupational Safety and Health Administration, 29 CFR Part
            1910.1030, 2001; Mangram et al., 1999).

        2.  Change masks between patients or during patient treatment if
            the mask becomes wet **(IB)** (\"Recommended infection
            control,\" 1993).

        3.  Clean with soap and water, or if visibly soiled, clean and
            disinfect reusable facial protective equipment (e.g.,
            clinician and patient protective eyewear or face shields)
            between patients **(II)** (\"Recommended infection
            control,\" 1993).

    B.  **Protective Clothing**

        1.  Wear protective clothing (e.g., reusable or disposable gown,
            laboratory coat, or uniform) that covers personal clothing
            and skin (e.g., forearms) likely to be soiled with blood,
            saliva, or other potentially infectious materials (OPIM)
            **(IB, IC)** (\"Update: universal precautions,\" 1988;
            \"Guidelines for prevention of transmission,\" 1989; Garner,
            1996; US Department of Labor, Occupational Safety and Health
            Administration, 29 CFR Part 1910.1030, 2001; Mangram et al.,
            1999).

        2.  Change protective clothing if visibly soiled (Association of
            Perioperative Registered Nurses, 2002); change immediately
            or as soon as feasible if penetrated by blood or other
            potentially infectious fluids **(IB, IC)** (US Department of
            Labor, Occupational Safety and Health Administration, 29 CFR
            Part 1910.1030, 2001).

        3.  Remove barrier protection, including gloves, mask, eyewear,
            and gown, before departing work area (e.g., dental patient
            care, instrument processing, or laboratory areas) **(IC)**
            (US Department of Labor, Occupational Safety and Health
            Administration, 29 CFR Part 1910.1030, 2001).

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    A.  **Gloves**

        1.  Wear medical gloves when a potential exists for contacting
            blood, saliva, OPIM, or mucous membranes **(IB, IC)**
            (\"Recommended infection-control practices,\" 1986;
            \"Recommended infection control,\" 1993; \"Update: universal
            precautions,\" 1988; \"Guidelines for prevention of
            transmission,\" 1989; US Department of Labor, Occupational
            Safety and Health Administration, 29 CFR Part 1910.1030,
            2001).

        2.  Wear a new pair of medical gloves for each patient, remove
            them promptly after use, and wash hands immediately to avoid
            transfer of microorganisms to other patients or environments
            **(IB)** (\"Recommended infection-control practices,\" 1986;
            \"Update: universal precautions,\" 1988; \"Guidelines for
            prevention of transmission,\" 1989; Boyce & Pittet, 2002).

        3.  Remove gloves that are torn, cut, or punctured as soon as
            feasible and wash hands before regloving **(IB, IC)** (US
            Department of Labor, Occupational Safety and Health
            Administration, 29 CFR Part 1910.1030, 2001; Wright et al.,
            1991, Dodds et al., 1988).

        4.  Do not wash surgeon´s or patient examination gloves before
            use or wash, disinfect, or sterilize gloves for reuse **(IB,
            IC)** (US Department of Labor, Occupational Safety and
            Health Administration, 29 CFR Part 1910.1030, 2001;
            Doebbeling et al., 1988; DeGroot-Kosolcharoen & Jones, 1989;
            Adams et al., 1992; Martin et al., 1988).

        5.  Ensure that appropriate gloves in the correct size are
            readily accessible **(IC)** (US Department of Labor,
            Occupational Safety and Health Administration, 29 CFR Part
            1910.1030, 2001).

        6.  Use appropriate gloves (e.g., puncture- and chemical
            resistant utility gloves) when cleaning instruments and
            performing housekeeping tasks involving contact with blood
            or OPIM **(IB, IC)** (\"Update: universal precautions,\"
            1988; US Department of Labor, Occupational Safety and Health
            Administration, 29 CFR Part 1910.1030, 2001; US Department
            of Labor, Occupational Safety and Health Administration,
            1994).

        7.  Consult with glove manufacturers regarding the chemical
            compatibility of glove material and dental materials used
            **(II)**.

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    A.  **Sterile Surgeon´s Gloves and Double Gloving** **During Oral
        Surgical Procedures**

        1.  Wear sterile surgeon´s gloves when performing oral surgical
            procedures **(IB)** (\"Recommended infection control,\"
            1993; \"Guidelines for prevention of transmission,\" 1989;
            Mangram et al., 1999).

        2.  No recommendation is offered regarding the effectiveness of
            wearing two pairs of gloves to prevent disease transmission
            during oral surgical procedures. The majority of studies
            among health-care personnel (HCP) and DHCP have demonstrated
            a lower frequency of inner glove perforation and visible
            blood on the surgeon´s hands when double gloves are worn;
            however, the effectiveness of wearing two pairs of gloves in
            preventing disease transmission has not been demonstrated
            **(Unresolved issue)**.

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V.  **Contact Dermatitis and Latex Hypersensitivity**

    A.  **General Recommendations**

        1.  Educate DHCP regarding the signs, symptoms, and diagnoses of
            skin reactions associated with frequent hand hygiene and
            glove use **(IB)** (Bolyard et al., 1998; \"The dental
            team,\" 1999; CDC, NIOSH, 1997).

        2.  Screen all patients for latex allergy (e.g., take health
            history and refer for medical consultation when latex
            allergy is suspected) **(IB)** (CDC, NIOSH, 1997).

        3.  Ensure a latex-safe environment for patients and DHCP with
            latex allergy **(IB)** (CDC, NIOSH, 1997).

        4.  Have emergency treatment kits with latex-free products
            available at all times **(II)** (CDC, NIOSH, 1997).

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VI. **Sterilization and Disinfection of Patient-Care Items**

    A.  **General Recommendations**

        1.  Use only U.S. Food and Drug Administration (FDA)-cleared
            medical devices for sterilization and follow the
            manufacturer´s instructions for correct use **(IB)**
            (Association for the Advancement of Medical Instrumentation,
            American National Standards Institute, 1998).

        2.  Clean and heat-sterilize critical dental instruments before
            each use **(IA)** (\"Recommended infection control,\" 1993;
            Mangram et al., 1999; CDC, in press; Sehulster & Chinn,
            2003; Food and Drug Administration, 1992; Favero & Bond,
            2001; \"Infection control recommendations for the dental
            office,\" 1996).

        3.  Clean and heat-sterilize semicritical items before each use
            **(IB)** (\"Recommended infection control,\" 1993; Favero &
            Bond, 2001; Miller & Palenik, 2001; \"Infection control
            recommendations for the dental office,\" 1996).

        4.  Allow packages to dry in the sterilizer before they are
            handled to avoid contamination **(IB)** (Association for the
            Advancement of Medical Instrumentation, American National
            Standards Institute, 2002).

        5.  Use of heat-stable semicritical alternatives is encouraged
            **(IB)** (\"Recommended infection control,\" 1993).

        6.  Reprocess heat-sensitive critical and semi-critical
            instruments by using FDA-cleared sterilant/ high-level
            disinfectants or an FDA-cleared low-temperature
            sterilization method (e.g., ethylene oxide). Follow
            manufacturer´s instructions for use of chemical
            sterilants/high-level disinfectants **(IB)** (CDC, in
            press).

        7.  Single-use disposable instruments are acceptable
            alternatives if they are used only once and disposed of
            correctly **(IB, IC)** (CDC, in press; Food and Drug
            Administration, 2001).

        8.  Do not use liquid chemical sterilants/high-level
            disinfectants for environmental surface disinfection or as
            holding solutions **(IB, IC)** (CDC, in press; US
            Environmental Protection Agency, 1996).

        9.  Ensure that noncritical patient-care items are
            barrier-protected or cleaned, or if visibly soiled, cleaned
            and disinfected after each use with an Environmental
            Protection Agency (EPA)-registered hospital disinfectant. If
            visibly contaminated with blood, use an EPA-registered
            hospital disinfectant with a tuberculocidal claim (i.e.,
            intermediate level) **(IB)** (\"Recommended infection
            control,\" 1993; CDC, in press; Sehulster & Chinn, 2003).

        10. Inform DHCP of all OSHA guidelines for exposure to chemical
            agents used for disinfection and sterilization. Using this
            report, identify areas and tasks that have potential for
            exposure **(IC)** (US Department of Labor, 1994).

    B.  **Instrument Processing Area**

        1.  Designate a central processing area. Divide the instrument
            processing area, physically or, at a minimum, spatially,
            into distinct areas for 1) receiving, cleaning, and
            decontamination; 2) preparation and packaging; 3)
            sterilization; and 4) storage. Do not store instruments in
            an area where contaminated instruments are held or cleaned
            **(II)** (Miller & Palenik, 1998; Association for the
            Advancement of Medical Instrumentation, American National
            Standards Institute, 1998 & 2002).

        2.  Train DHCP to employ work practices that prevent
            contamination of clean areas **(II)**.

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    A.  **Receiving, Cleaning, and Decontamination Work Area**

        1.  Minimize handling of loose contaminated instruments during
            transport to the instrument processing area. Use
            work-practice controls (e.g., carry instruments in a covered
            container) to minimize exposure potential **(II)**. Clean
            all visible blood and other contamination from dental
            instruments and devices before sterilization or disinfection
            procedures **(IA)** (CDC, in press; Favero & Bond, 2001;
            Parker & Johnson, 1995; Alfa et al., 1998; Rutala & Weber,
            1998).

        2.  Use automated cleaning equipment (e.g., ultrasonic cleaner
            or washer-disinfector) to remove debris to improve cleaning
            effectiveness and decrease worker exposure to blood **(IB)**
            (\"Recommended infection control,\" 1993; Miller et al.,
            2000).

        3.  Use work-practice controls that minimize contact with sharp
            instruments if manual cleaning is necessary (e.g.,
            long-handled brush) **(IC)** (US Department of Labor,
            Occupational Safety and Health Administration, \"OSHA
            instructions,\" 2001).

        4.  Wear puncture- and chemical-resistant/heavy-duty utility
            gloves for instrument cleaning and decontamination
            procedures **(IB)** (\"Update: universal precautions,\"
            1988).

        5.  Wear appropriate personal protection equipment (PPE) (e.g.,
            mask, protective eyewear, and gown) when splashing or
            spraying is anticipated during cleaning **(IC)** (US
            Department of Labor, Occupational Safety and Health
            Administration, 29 CFR Part 1910.1030, 2001).

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    A.  **Preparation and Packaging**

        1.  Use an internal chemical indicator in each package. If the
            internal indicator cannot be seen from outside the package,
            also use an external indicator **(II)** (CDC, in press;
            Association for the Advancement of Medical Instrumentation,
            1999; Association for the Advancement of Medical
            Instrumentation, American National Standards Institute,
            1993).

        2.  Use a container system or wrapping compatible with the type
            of sterilization process used and that has received FDA
            clearance **(IB)** (CDC, in press; Association for the
            Advancement of Medical Instrumentation, American National
            Standards Institute, 2002; Rutala & Weber, 2000).

        3.  Before sterilization of critical and semicritical
            instruments, inspect instruments for cleanliness, then wrap
            or place them in containers designed to maintain sterility
            during storage (e.g., cassettes and organizing trays)
            **(IA)** (\"Recommended infection control,\" 1993;
            Association for the Advancement of Medical Instrumentation,
            American National Standards Institute, 2002; Ninemeier,
            1998; Rutala & Weber, 2000).

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    A.  **Sterilization of Unwrapped Instruments**

        1.  Clean and dry instruments before the unwrapped sterilization
            cycle **(IB)** (Association for the Advancement of Medical
            Instrumentation, American National Standards Institute,
            1998).

        2.  Use mechanical and chemical indicators for each unwrapped
            sterilization cycle (i.e., place an internal chemical
            indicator among the instruments or items to be sterilized)
            **(IB)** (CDC, in press; Association for the Advancement of
            Medical Instrumentation, American National Standards
            Institute, 1996).

        3.  Allow unwrapped instruments to dry and cool in the
            sterilizer before they are handled to avoid contamination
            and thermal injury **(II)** (Miller & Palenik, 2001).

        4.  Semicritical instruments that will be used immediately or
            within a short time can be sterilized unwrapped on a tray or
            in a container system, provided that the instruments are
            handled aseptically during removal from the sterilizer and
            transport to the point of use **(II)**.

        5.  Critical instruments intended for immediate reuse can be
            sterilized unwrapped if the instruments are maintained
            sterile during removal from the sterilizer and transport to
            the point of use (e.g., transported in a sterile covered
            container) **(IB)** (Association for the Advancement of
            Medical Instrumentation, American National Standards
            Institute, 1996).

        6.  Do not sterilize implantable devices unwrapped **(IB)**
            (CDC, in press; Association for the Advancement of Medical
            Instrumentation, American National Standards Institute,
            2002).

        7.  Do not store critical instruments unwrapped **(IB)**
            (Association for the Advancement of Medical Instrumentation,
            American National Standards Institute, 1998).

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    A.  **Sterilization Monitoring**

        1.  Use mechanical, chemical, and biological monitors according
            to the manufacturer´s instructions to ensure the
            effectiveness of the sterilization process **(IB)**
            (Association for the Advancement of Medical Instrumentation,
            American National Standards Institute, 1998; Greene, 1992;
            Favero, 1998).

        2.  Monitor each load with mechanical (e.g., time, temperature,
            and pressure) and chemical indicators **(II)** (CDC, in
            press; Association for the Advancement of Medical
            Instrumentation, American National Standards Institute,
            1998).

        3.  Place a chemical indicator on the inside of each package. If
            the internal indicator is not visible from the outside, also
            place an exterior chemical indicator on the package **(II)**
            (CDC, in press; Association for the Advancement of Medical
            Instrumentation, 1999; Association for the Advancement of
            Medical Instrumentation, American National Standards
            Institute, 1993).

        4.  Place items/packages correctly and loosely into the
            sterilizer so as not to impede penetration of the sterilant
            **(IB)** (CDC, in press).

        5.  Do not use instrument packs if mechanical or chemical
            indicators indicate inadequate processing **(IB)** (CDC, in
            press; Association for the Advancement of Medical
            Instrumentation, American National Standards Institute, 1998
            & 2002).

        6.  Monitor sterilizers at least weekly by using a biological
            indicator with a matching control (i.e., biological
            indicator and control from same lot number) **(IB)**
            (\"Recommended infection control,\" 1993; Garner & Favero,
            1986; CDC, in press; Association for the Advancement of
            Medical Instrumentation, American National Standards
            Institute, 2002; Greene, 1992; Favero, 1998).

        7.  Use a biological indicator for every sterilizer load that
            contains an implantable device. Verify results before using
            the implantable device, whenever possible **(IB)** (CDC, in
            press; Association for the Advancement of Medical
            Instrumentation, American National Standards Institute,
            1998).

        8.  The following are recommended in the case of a positive
            spore test:

            a.  Remove the sterilizer from service and review
                sterilization procedures (e.g., work practices and use
                of mechanical and chemical indicators) to determine
                whether operator error could be responsible **(II)**
                (\"Guidelines for prevention of transmission,\" 1989).

            b.  Retest the sterilizer by using biological, mechanical,
                and chemical indicators after correcting any identified
                procedural problems **(II)**.

            c.  If the repeat spore test is negative, and mechanical and
                chemical indicators are within normal limits, put the
                sterilizer back in service **(II)** (Garner & Favero,
                1986; CDC, in press).

        9.  The following are recommended if the repeat spore test is
            positive:

            a.  Do not use the sterilizer until it has been inspected or
                repaired or the exact reason for the positive test has
                been determined **(II)** (Garner & Favero, 1986; CDC, in
                press).

            b.  Recall, to the extent possible, and reprocess all items
                processed since the last negative spore test **(II)**
                (Garner & Favero, 1986; CDC, in press; Association of
                Operating Room Nurses, 1987).

            c.  Before placing the sterilizer back in service,
                rechallenge the sterilizer with biological indicator
                tests in three consecutive empty chamber sterilization
                cycles after the cause of the sterilizer failure has
                been determined and corrected **(II)** (Garner & Favero,
                1986; CDC, in press; Association of Operating Room
                Nurses, 1987).

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        1.  Maintain sterilization records (i.e., mechanical, chemical,
            and biological) in compliance with state and local
            regulations **(IB)** (CDC, in press).

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    G.  **Storage Area for Sterilized Items and Clean Dental Supplies**

        1.  Implement practices on the basis of date- or event-related
            shelf-life for storage of wrapped, sterilized instruments
            and devices **(IB)** (CDC, in press; Mayworm, 1984).

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        1.  Even for event-related packaging, at a minimum, place the
            date of sterilization, and if multiple sterilizers are used
            in the facility, the sterilizer used, on the outside of the
            packaging material to facilitate the retrieval of processed
            items in the event of a sterilization failure **(IB)** (CDC,
            in press; Association for the Advancement of Medical
            Instrumentation, American National Standards Institute,
            2002).

        2.  Examine wrapped packages of sterilized instruments before
            opening them to ensure the barrier wrap has not been
            compromised during storage **(II)** (CDC, in press; Mayworm,
            1984).

        3.  Reclean, repack, and resterilize any instrument package that
            has been compromised **(II)**.

        4.  Store sterile items and dental supplies in covered or closed
            cabinets, if possible **(II)** (Cardo & Sehulster, 1999).

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VII. **Environmental Infection Control**

     A.  **General Recommendations**

         1.  Follow the manufacturers´ instructions for correct use of
             cleaning and EPA-registered hospital disinfecting products
             **(IB, IC)** (CDC, in press; Sehulster & Chinn, 2003; US
             Environmental Protection Agency, 1996).

         2.  Do not use liquid chemical sterilants/high-level
             disinfectants for disinfection of environmental surfaces
             (clinical contact or housekeeping) **(IB, IC)** (CDC, in
             press; Sehulster & Chinn, 2003; US Environmental Protection
             Agency, 1996.

         3.  Use PPE, as appropriate, when cleaning and disinfecting
             environmental surfaces. Such equipment might include gloves
             (e.g., puncture- and chemical-resistant utility),
             protective clothing (e.g., gown, jacket, or lab coat), and
             protective eyewear/face shield, and mask **(IC)** (US
             Department of Labor, Occupational Safety and Health
             Administration, 29 CFR Part 1910.1030, 2001; US Department
             of Labor, Occupational Safety and Health Administration,
             1994).

     B.  **Clinical Contact Surfaces**

         1.  Use surface barriers to protect clinical contact surfaces,
             particularly those that are difficult to clean (e.g.,
             switches on dental chairs) and change surface barriers
             between patients **(II)** (\"Recommended infection-control
             practices,\" 1986; \"Recommended infection control,\" 1993;
             Miller & Palenik, 2001; Crawford, 1987).

         2.  Clean and disinfect clinical contact surfaces that are not
             barrier-protected by using an EPA-registered hospital
             disinfectant with a low- (i.e., human immunodeficiency
             virus \[HIV\] and hepatitis B virus \[HBV\] label claims)
             to intermediate-level (i.e., tuberculocidal claim) activity
             after each patient. Use an intermediate-level disinfectant
             if visibly contaminated with blood **(IB)** (CDC, in press;
             \"Recommended infection control,\" 1993; Sehulster & Chinn,
             2003).

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     A.  **Housekeeping Surfaces**

         1.  Clean housekeeping surfaces (e.g., floors, walls, and
             sinks) with a detergent and water or an EPA-registered
             hospital disinfectant/detergent on a routine basis,
             depending on the nature of the surface and type and degree
             of contamination, and as appropriate, based on the location
             in the facility, and when visibly soiled **(IB)** (CDC, in
             press; Sehulster & Chinn, 2003).

         2.  Clean mops and cloths after use and allow to dry before
             reuse; or use single-use, disposable mop heads or cloths
             **(II)** (CDC, in press; Sehulster & Chinn, 2003).

         3.  Prepare fresh cleaning or EPA-registered disinfecting
             solutions daily and as instructed by the manufacturer.
             **(II)** (CDC, in press; Sehulster & Chinn, 2003).

         4.  Clean walls, blinds, and window curtains in patient-care
             areas when they are visibly dusty or soiled **(II)**
             (Garner & Favero, 1986; Sehulster & Chinn, 2003;).

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     A.  **Spills of Blood and Body Substances**

         1.  Clean spills of blood or OPIM and decontaminate surface
             with an EPA-registered hospital disinfectant with low-
             (i.e., HBV and HIV label claims) to intermediate-level
             (i.e., tuberculocidal claim) activity, depending on size of
             spill and surface porosity **(IB, IC)** (US Department of
             Labor, Occupational Safety and Health Administration, 29
             CFR Part 1910.1030, 2001; \"Recommendations for prevention
             of HIV,\" 1987).

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     A.  **Carpet and Cloth Furnishings**

         1.  Avoid using carpeting and cloth-upholstered furnishings in
             dental operatories, laboratories, and instrument processing
             areas **(II)** (Garner & Favero, 1986; Gerson et al., 1994;
             Suzuki et al. 1984; Skoutelis et al., 1994).

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     A.  **Regulated Medical Waste**

         1.  General Recommendations

             a.  Develop a medical waste management program. Disposal of
                 regulated medical waste must follow federal, state, and
                 local regulations **(IC)** (US Department of Labor,
                 Occupational Safety and Health Administration, 29 CFR
                 Part 1910.1030, 2001; US Environmental Protection
                 Agency, 1997).

             b.  Ensure that DHCP who handle and dispose of regulated
                 medical waste are trained in appropriate handling and
                 disposal methods and informed of the possible health
                 and safety hazards **(IC)** (US Department of Labor,
                 Occupational Safety and Health Administration, 29 CFR
                 Part 1910.1030, 2001).

         2.  Management of Regulated Medical Waste in Dental Health-Care
             Facilities

             a.  Use a color-coded or labeled container that prevents
                 leakage (e.g., biohazard bag) to contain nonsharp
                 regulated medical waste **(IC)** (US Department of
                 Labor, Occupational Safety and Health Administration,
                 29 CFR Part 1910.1030, 2001).

             b.  Place sharp items (e.g., needles, scalpel blades,
                 orthodontic bands, broken metal instruments, and burs)
                 in an appropriate sharps container (e.g., puncture
                 resistant, color-coded, and leakproof). Close container
                 immediately before removal or replacement to prevent
                 spillage or protrusion of contents during handling,
                 storage, transport, or shipping **(IC)** (\"Recommended
                 infection control,\" 1993; \"Guidelines for prevention
                 of transmission,\" 1989; US Department of Labor,
                 Occupational Safety and Health Administration, 29 CFR
                 Part 1910.1030, 2001; \"Recommendations for prevention
                 of HIV,\" 1987; CDC, NIOSH, 1998).

             c.  Pour blood, suctioned fluids, or other liquid waste
                 carefully into a drain connected to a sanitary sewer
                 system, if local sewage discharge requirements are met
                 and the state has declared this an acceptable method of
                 disposal. Wear appropriate PPE while performing this
                 task **(IC)** (\"Update: universal precautions,\" 1988;
                 Garner & Favero, 1986; US Department of Labor,
                 Occupational Safety and Health Administration, 29 CFR
                 Part 1910.1030, 2001).

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VIII. **Dental Unit Waterlines, Biofilm, and Water Quality**

      A.  **General Recommendations**

          1.  Use water that meets EPA regulatory standards for drinking
              water (i.e., [\<]{.underline}500 CFU/mL of heterotrophic
              water bacteria) for routine dental treatment output water
              **(IB, IC)** (US Environmental Protection Agency, 1999;
              American Public Health Association, American Water Works
              Association, Water Environment Foundation, 1999).

          2.  Consult with the dental unit manufacturer for appropriate
              methods and equipment to maintain the recommended quality
              of dental water **(II)** (Shearer, 1996).

          3.  Follow recommendations for monitoring water quality
              provided by the manufacturer of the unit or waterline
              treatment product **(II)**.

          4.  Discharge water and air for a minimum of 20 to 30 seconds
              after each patient, from any device connected to the
              dental water system that enters the patient´s mouth (e.g.,
              handpieces, ultrasonic scalers, and air/water syringes)
              **(II)** (\"Recommended infection control,\" 1993; Bagga
              et al., 1984; Scheid, Rosen, & Beck, 1990).

          5.  Consult with the dental unit manufacturer on the need for
              periodic maintenance of antiretraction mechanisms **(IB)**
              (\"Recommended infection control,\" 1993; Bagga et al.,
              1984).

      B.  **Boil-Water Advisories**

          1.  The following apply while a boil-water advisory is in
              effect:

              a.  Do not deliver water from the public water system to
                  the patient through the dental operative unit,
                  ultrasonic scaler, or other dental equipment that uses
                  the public water system **(IB, IC)** (US Environmental
                  Protection Agency, 1999; American Public Health
                  Association, American Water Works Association, Water
                  Environment Foundation, 1999; CDC, Working Group on
                  Waterborne Cryptosporidiosis, 1997; \"Assessing the
                  public health threat,\" 1995; Kramer et al., 1996).

              b.  Do not use water from the public water system for
                  dental treatment, patient rinsing, or handwashing
                  **(IB, IC)** (US Environmental Protection Agency,
                  1999; American Public Health Association, American
                  Water Works Association, Water Environment Foundation,
                  1999; CDC, Working Group on Waterborne
                  Cryptosporidiosis, 1997; \"Assessing the public health
                  threat,\" 1995; Kramer et al., 1996).

              c.  For handwashing, use antimicrobial containing products
                  that do not require water for use (e.g., alcohol-based
                  hand rubs). If hands are visibly contaminated, use
                  bottled water, if available, and soap for handwashing
                  or an antiseptic towelette **(IB, IC)** (US Department
                  of Labor, Occupational Safety and Health
                  Administration, 29 CFR Part 1910.1030, 2001; APIC,
                  1995).

          2.  The following apply when the boil-water advisory is
              cancelled:

              a.  Follow guidance given by the local water utility
                  regarding adequate flushing of waterlines. If no
                  guidance is provided, flush dental waterlines and
                  faucets for 1 to 5 minutes before using for patient
                  care **(IC)**) (Sehulster & Chinn, 2003; CDC, Working
                  Group on Waterborne Cryptosporidiosis, 1997; Office of
                  Water, US Environmental Protection Agency, 2000; US
                  Environmental Protection Agency, 2000).

              b.  Disinfect dental waterlines as recommended by the
                  dental unit manufacturer **(II)**.

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IX. **Special Considerations**

    A.  **Dental Handpieces and Other Devices Attached to Air and
        Waterlines**

        1.  Clean and heat-sterilize handpieces and other intraoral
            instruments that can be removed from the air and waterlines
            of dental units between patients **(IB, IC)** (\"Recommended
            infection control,\" 1993; Food and Drug Administration,
            1992; Pratt et al., 1999; Lewis et al., 1992; Lewis & Boe,
            1992; Kolstad, 1998; \"Infection control recommendations for
            the dental office,\" 1996).

        2.  Follow the manufacturer´s instructions for cleaning,
            lubrication, and sterilization of handpieces and other
            intraoral instruments that can be removed from the air and
            waterlines of dental units **(IB)** (Kuehne, Cohen, &
            Monroe, 1992; Andersen, Fiehn, & Larsen, 1999; Leonard &
            Charlton, 1999).

        3.  Do not surface-disinfect, use liquid chemical sterilants, or
            ethylene oxide on handpieces and other intraoral instruments
            that can be removed from the air and waterlines of dental
            units **(IC)** (\"Recommended infection control,\" 1993;
            Food and Drug Administration, 1992; Parker & Johnson, 1995;
            Pratt et al., 1999).

        4.  Do not advise patients to close their lips tightly around
            the tip of the saliva ejector to evacuate oral fluids
            **(II)** (Barbeau et al., 1998; Mann, Campbell, & Crawford,
            1996; Watson & Whitehouse, 1993).

    B.  **Dental Radiology**

        1.  Wear gloves when exposing radiographs and handling
            contaminated film packets. Use other PPE (e.g., protective
            eyewear, mask, and gown) as appropriate if spattering of
            blood or other body fluids is likely **(IA, IC)** (Garner,
            1996; US Department of Labor, Occupational Safety and Health
            Administration, 29 CFR Part 1910.1030, 2001).

        2.  Use heat-tolerant or disposable intraoral devices whenever
            possible (e.g., film-holding and positioning devices). Clean
            and heat-sterilize heat-tolerant devices between patients.
            At a minimum, high-level disinfect semicritical
            heat-sensitive devices, according to manufacturer´s
            instructions **(IB)** (CDC, in press).

        3.  Transport and handle exposed radiographs in an aseptic
            manner to prevent contamination of developing equipment
            **(II)**.

        4.  The following apply for digital radiography sensors:

            a.  Use FDA-cleared barriers **(IB)** (CDC, in press).

            b.  Clean and heat-sterilize, or high-level disinfect,
                between patients, barrier-protected semicritical items.
                If the item cannot tolerate these procedures then, at a
                minimum, protect with an FDA-cleared barrier and clean
                and disinfect with an EPA-registered hospital
                disinfectant with intermediate-level (i.e.,
                tuberculocidal claim) activity, between patients.
                Consult with the manufacturer for methods of
                disinfection and sterilization of digital radiology
                sensors and for protection of associated computer
                hardware **(IB)** (CDC, in press).

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    C.  **Aseptic Technique for Parenteral Medications**

        1.  Do not administer medication from a syringe to multiple
            patients, even if the needle on the syringe is changed
            **(IA)** (American Society of Anesthesiologists, 1999).

        2.  Use single-dose vials for parenteral medications when
            possible **(II)** (\"ASHP guidelines on quality assurance,\"
            2000; Green et al., 1995).

        3.  Do not combine the leftover contents of single-use vials for
            later use **(IA)** (\"ASHP guidelines on quality
            assurance,\" 2000; Green et al., 1995).

        4.  The following apply if multidose vials are used:

            a.  Cleanse the access diaphragm with 70% alcohol before
                inserting a device into the vial **(IA)** (Plott,
                Wagner, & Tyring, 1990; Arrington et al., 1990).

            b.  Use a sterile device to access a multiple-dose vial and
                avoid touching the access diaphragm. Both the needle and
                syringe used to access the multidose vial should be
                sterile. Do not reuse a syringe even if the needle is
                changed **(IA)** (Plott, Wagner, & Tyring, 1990;
                Arrington et al., 1990).

            c.  Keep multidose vials away from the immediate patient
                treatment area to prevent inadvertent contamination by
                spray or spatter **(II)**.

            d.  Discard the multidose vial if sterility is compromised
                **(IA)** (Plott, Wagner, & Tyring, 1990; Arrington et
                al., 1990).

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        1.  Use fluid infusion and administration sets (i.e., IV bags,
            tubings, and connections) for one patient only and dispose
            of appropriately **(IB)** (American Society of
            Anesthesiologists, 1999).

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    C.  **Single-Use (Disposable) Devices**

        1.  Use single-use devices for one patient only and dispose of
            them appropriately **(IC)** (Food and Drug Administration,
            2001).

    D.  **Preprocedural Mouth Rinses**

        1.  No recommendation is offered regarding use of preprocedural
            antimicrobial mouth rinses to prevent clinical infections
            among DHCP or patients. Although studies have demonstrated
            that a preprocedural antimicrobial rinse (e.g.,
            chlorhexidine gluconate, essential oils, or povidone-iodine)
            can reduce the level of oral microorganisms in aerosols and
            spatter generated during routine dental procedures and can
            decrease the number of microorganisms introduced in the
            patient´s bloodstream during invasive dental procedures
            (Litsky, Mascis, & Litsky, 1970; Mohammed & Monserrate,
            1970; Wyler, Miller, & Micik, 1971; Muir et al., 1978; Fine,
            Furgang et al., 1992; Fine, Yip et al., 1993; Fine et al.,
            1993; Logothetis & Martinez-Welles, 1995; Klyn et al.,
            2001), the scientific evidence is inconclusive that using
            these rinses prevents clinical infections among DHCP or
            patients (see discussion, Preprocedural Mouth Rinses in the
            original guideline document) **(Unresolved issue)**.

    E.  **Oral Surgical Procedures**

        1.  The following apply when performing oral surgical
            procedures:

            a.  Perform surgical hand antisepsis by using an
                antimicrobial product (e.g., antimicrobial soap and
                water, or soap and water followed by alcohol-based hand
                scrub with persistent activity) before donning sterile
                surgeon´s gloves **(IB)** (Price, 1938; Dewar & Gravens,
                1973; Lowbury & Lilly, 1960; Rotter, 1999; Widmer 2000;
                Larson et al., 1990; Mangram et al., 1999).

            b.  Use sterile surgeon´s gloves **(IB)** (\"Recommended
                infection control,\" 1993; \"Update: universal
                precautions,\" 1988; Garner, 1986; CDC, 2002; Mangram et
                al., 1999).

            c.  Use sterile saline or sterile water as a
                coolant/irrigant when performing oral surgical
                procedures. Use devices specifically designed for
                delivering sterile irrigating fluids (e.g., bulb
                syringe, single-use disposable products, and
                sterilizable tubing) **(IB)** (\"Recommended infection
                control,\" 1993; Garner, 1986).

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    G.  **Handling of Biopsy Specimens**

        1.  During transport, place biopsy specimens in a sturdy,
            leakproof container labeled with the biohazard symbol
            **(IC)** (\"Recommended infection control,\" 1993; US
            Department of Labor, Occupational Safety and Health
            Administration, 29 CFR Part 1910.1030, 2001; US Department
            of Labor, Occupational Safety and Health Administration,
            \"OSHA instruction,\" 2001).

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        ```
        1.  If a biopsy specimen container is visibly contaminated,
            clean and disinfect the outside of a container or place it
            in an impervious bag labeled with the biohazard symbol,
            **(IC)** (\"Recommended infection control,\" 1993; US
            Department of Labor, Occupational Safety and Health
            Administration, 29 CFR Part 1910.1030, 2001).

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    ```
    F.  **Handling of Extracted Teeth**

        1.  Dispose of extracted teeth as regulated medical waste unless
            returned to the patient **(IC)** (US Department of Labor,
            Occupational Safety and Health Administration, 29 CFR Part
            1910.1030, 2001; US Department of Labor, Occupational Safety
            and Health Administration, \"OSHA instruction,\" 2001).

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        ```
        1.  Do not dispose of extracted teeth containing amalgam in
            regulated medical waste intended for incineration **(II)**.

        2.  Clean and place extracted teeth in a leakproof container,
            labeled with a biohazard symbol, and maintain hydration for
            transport to educational institutions or a dental laboratory
            **(IC)** (US Department of Labor, Occupational Safety and
            Health Administration, 29 CFR Part 1910.1030, 2001; US
            Department of Labor, Occupational Safety and Health
            Administration, \"OSHA instruction,\" 2001).

        3.  Heat-sterilize teeth that do not contain amalgam before they
            are used for educational purposes **(IB)** (Tate & White,
            1991; Pantera & Schuster, 1990; Parsel et al., 1998).

    G.  **Dental Laboratory**

        1.  Use PPE when handling items received in the laboratory until
            they have been decontaminated **(IA, IC)**
            (\"Recommendations for prevention of HIV,\" 1987; \"Update:
            universal precautions,\" 1988; Garner, 1996; US Department
            of Labor, Occupational Safety and Health Administration, 29
            CFR Part 1910.1030, 2001; \"Recommended infection control,\"
            1993).

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        ```
        1.  Before they are handled in the laboratory, clean, disinfect,
            and rinse all dental prostheses and prosthodontic materials
            (e.g., impressions, bite registrations, occlusal rims, and
            extracted teeth) by using an EPA-registered hospital
            disinfectant having at least an intermediate-level (i.e.,
            tuberculocidal claim) activity **(IB)** (\"Recommended
            infection control,\" 1993; Favero & Bond, 2001; Rutala &
            Weber, 1998; \"Infection control recommendations for the
            dental office,\" 1996).

        2.  Consult with manufacturers regarding the stability of
            specific materials (e.g., impression materials) relative to
            disinfection procedures **(II)**.

        3.  Include specific information regarding disinfection
            techniques used (e.g., solution used and duration), when
            laboratory cases are sent offsite and on their return
            **(II)** (\"Recommended infection control,\" 1993;
            \"Infection control recommendations for the dental office,\"
            1996; Kugel et al., 2000).

        4.  Clean and heat-sterilize heat-tolerant items used in the
            mouth (e.g., metal impression trays and face-bow forks)
            **(IB)** (\"Recommended infection control,\" 1993;
            \"Infection control recommendations for the dental office,\"
            1996).

        5.  Follow manufacturers´ instructions for cleaning and
            sterilizing or disinfecting items that become contaminated
            but do not normally contact the patient (e.g., burs,
            polishing points, rag wheels, articulators, case pans, and
            lathes). If manufacturer instructions are unavailable, clean
            and heat sterilize heat-tolerant items or clean and
            disinfect with an EPA-registered hospital disinfectant with
            low- (HIV, HBV effectiveness claim) to intermediate- level
            (tuberculocidal claim) activity, depending on the degree of
            contamination **(II)**.

    H.  **Laser/Electrosurgery Plumes/Surgical Smoke**

        1.  No recommendation is offered regarding practices to reduce
            DHCP exposure to laser plumes/ surgical smoke when using
            lasers in dental practice. Practices to reduce HCP exposure
            to laser plumes/surgical smoke have been suggested,
            including use of a) standard precautions (e.g.,
            high-filtration surgical masks and possibly full face
            shields) (Streifel, 1997); b) central room suction units
            with in-line filters to collect particulate matter from
            minimal plumes; and c) dedicated mechanical smoke exhaust
            systems with a high-efficiency filter to remove substantial
            amounts of laser-plume particles. The effect of the exposure
            (e.g., disease transmission or adverse respiratory effects)
            on DHCP from dental applications of lasers has not been
            adequately evaluated (see previous discussion,
            Laser/Electrosurgery Plumes or Surgical Smoke in original
            guideline document) **(Unresolved issue)**.

    I.  ***Mycobacterium tuberculosis***

        1.  General Recommendations

            a.  Educate all DHCP regarding the recognition of signs,
                symptoms, and transmission of TB **(IB)** (\"Guidelines
                for preventing the transmission of Mycobacterium
                tuberculosis,\" 1994; Cleveland et al., 1995).

            b.  Conduct a baseline tuberculin skin test (TST),
                preferably by using a two-step test, for all DHCP who
                might have contact with persons with suspected or
                confirmed active TB, regardless of the risk
                classification of the setting **(IB)** (\"Guidelines for
                preventing the transmission of Mycobacterium
                tuberculosis,\" 1994).

            c.  Assess each patient for a history of TB as well as
                symptoms indicative of TB and document on the medical
                history form **(IB)** (\"Guidelines for preventing the
                transmission of Mycobacterium tuberculosis,\" 1994;
                Cleveland et al., 1995).

            d.  Follow CDC recommendations for 1) developing,
                maintaining, and implementing a written TB
                infection-control plan; 2) managing a patient with
                suspected or active TB; 3) completing a community
                risk-assessment to guide employee TSTs and follow-up;
                and 4) managing DHCP with TB disease **(IB)**
                (\"Recommended infection control,\" 1993; Cleveland et
                al., 1995).

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        ```
        1.  The following apply for patients known or suspected to have
            active TB:

            a.  Evaluate the patient away from other patients and DHCP.
                When not being evaluated, the patient should wear a
                surgical mask or be instructed to cover mouth and nose
                when coughing or sneezing **(IB)** (\"Guidelines for
                preventing the transmission of Mycobacterium
                tuberculosis,\" 1994; Cleveland et al., 1995).

            b.  Defer elective dental treatment until the patient is
                noninfectious **(IB)** (\"Guidelines for preventing the
                transmission of Mycobacterium tuberculosis,\" 1994;
                Cleveland et al., 1995).

            c.  Refer patients requiring urgent dental treatment to a
                previously identified facility with TB engineering
                controls and a respiratory protection program **(IB)**
                (\"Guidelines for preventing the transmission of
                Mycobacterium tuberculosis,\" 1994; Cleveland et al.,
                1995).

    J.  **Creutzfeldt-Jakob Disease (CJD) and Other Prion Diseases**

        1.  No recommendation is offered regarding use of special
            precautions in addition to standard precautions when
            treating known Creutzfeldt-Jakob disease (CJD) or variant
            Creutzfeldt-Jakob disease (vCJD) patients. Potential
            infectivity of oral tissues in CJD or vCJD patients is an
            unresolved issue. Scientific data indicate the risk, if any,
            of sporadic CJD transmission during dental and oral surgical
            procedures is low to nil. Until additional information
            exists regarding the transmissibility of CJD or vCJD during
            dental procedures, special precautions in addition to
            standard precautions might be indicated when treating known
            CJD or vCJD patients; a list of such precautions is provided
            for consideration without recommendation (see
            Creutzfeldt-Jakob Disease and Other Prion Diseases in
            original guideline document) **(Unresolved issue)**.

    K.  **Program Evaluation**

        1.  Establish routine evaluation of the infection control
            program, including evaluation of performance indicators, at
            an established frequency **(II)** (\"Framework for program
            evaluation,\" 1999; Institute of Medicine, 1999).

**[Definitions]{.underline}**:

**Recommendation Rating Scheme**

**Category IA**. Strongly recommended for implementation and strongly
supported by well-designed experimental, clinical, or epidemiologic
studies

**Category IB**. Strongly recommended for implementation and supported
by experimental, clinical, or epidemiologic studies and a strong
theoretical rationale

**Category IC**. Required for implementation as mandated by federal or
state regulation or standard. When IC is used, a second rating can be
included to provide the basis of existing scientific data, theoretical
rationale, and applicability. Because of state differences, the reader
should not assume that the absence of a IC implies the absence of state
regulations.

**Category II**. Suggested for implementation and supported by
suggestive clinical or epidemiologic studies or a theoretical rationale

**Unresolved issue**. No recommendation. Insufficient evidence or no
consensus regarding efficacy exists.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=4540)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Each recommendation is categorized on the basis of existing scientific
data, theoretical rationale, and applicability (see \"Major
Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Prevention of or reduced potential for disease transmission from patient
to dental health-care personnel (DHCP), from dental health-care
personnel to patient, and from patient to patient.

#### POTENTIAL HARMS

Not stated

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Contraindications and precautions regarding immunizations for
health-care personnel are documented in Appendix B of the original
guideline document.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This report does not include any discussion of the unlabeled use of
commercial products or products for investigational use.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM.
Guidelines for infection control in dental health-care settings\--2003.
MMWR Recomm Rep 2003 Dec 19;52(RR-17):1-61. \[471 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14685139)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Dec 19

#### GUIDELINE DEVELOPER(S)

Centers for Disease Control and Prevention - Federal Government Agency
\[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Report Prepared by*: William G. Kohn, DDS, Division of Oral Health,
National Center for Chronic Disease Prevention and Health Promotion,
CDC; Amy S. Collins, MPH, Division of Oral Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC; Jennifer L.
Cleveland, DDS, Division of Oral Health, National Center for Chronic
Disease Prevention and Health Promotion, CDC; Jennifer A. Harte, DDS,
United States Air Force Dental Investigation Service, Great Lakes,
Illinois; Kathy J. Eklund, MHP, The Forsyth Institute, Boston,
Massachusetts; Dolores M. Malvitz, DrPH, Division of Oral Health,
National Center for Chronic Disease Prevention and Health Promotion, CDC

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The subject matter experts wish to disclose they have no financial
interests or other relationships with the manufacture of commercial
products, providers of commercial services, or commercial supporters.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the Centers for Disease Control and
Prevention (CDC) Web site:

-   [HTML Format](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm)

-   [Portable Document Format
    (PDF)](http://www.cdc.gov/mmwr/PDF/rr/rr5217.pdf)

Print copies: Available from the Centers for Disease Control and
Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased
from the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402-9325; (202) 783-3238.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on June 4, 2004.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

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Date Modified: 11/3/2008