You have several acceptable choices for accomplishing effective hand hygiene in your practice. These alternatives are included in the comprehensive 2003 Centers for Disease Control and Prevention (CDC) infection control recommendations for dentistry. Either plain soap or an antimicrobial soap and water can be used for nonsurgical dental procedures, such as examinations, preventive procedures, restorative dentistry, orthodontics, and endodontic procedures. If hands are not visibly soiled or contaminated with blood or other potentially infectious material (ie, saliva, bloody saliva), use of a waterless, alcohol-based hand rub is also acceptable. It is important to note the specific wording of the recommendation: “If hands are not visibly soiled, an alcohol-based hand rub can also be used.” 
While the use of an antiseptic agent provides effective antimicrobial activity against overgrowth of normal, commensal, and transient microflora; the basic tenet of hand washing is to clean hands. Several factors must be considered when deciding what approach will be used. These factors include the type of procedures performed in the clinical facility, degree of anticipated contamination during patient treatment, and whether or not residual or persistent antimicrobial activity is needed after hand hygiene procedures. Thus, you can choose to routinely use a liquid soap or antimicrobial antiseptic and water. Use of plain soap is appropriate for removing skin debris and microbial contamination. Since intact skin is a primary barrier, any non-antimicrobial soap considered should contain ingredients to prevent skin irritation and dryness to help preserve epithelial integrity. Optimal properties for use of an antimicrobial antiseptic with water should include broad antimicrobial spectrum of activity, ability to act fast, and a residual, persistent effectiveness. 
The key for use of whatever hand hygiene agent that you decide upon is compliance. Several clinical reports published in the medical literature have indicated that the incidence of healthcare-associated infections decreased as healthcare workers (HCW) demonstrated improved hand hygiene practices. Other studies have also shown that compliance increased with use of alcohol-based hand rubs. As such, the 2002 CDC guidelines for hand hygiene in healthcare settings that served as the basis for the 2003 dental recommendations, advocated a combined protocol of hand washing and alcohol-based agents for routine hand antisepsis.

Question 2. Are there any recommendations for the use of hand lotion in clinical settings?
Lotions are recommended to reduce drying of hands and possible dermatitis from glove use. Use of lotions is especially important in healthcare where HCW frequently wash their hands 20 or more times a day, thereby leading to an increased potential for chronic irritation dermatitis. Previously, the overwhelming majority of commercial lotions were petroleum-based. While they can lubricate and replenish keratinized epithelial tissues, these formulations also unfortunately react with gloves being worn (primarily latex gloves) and increase their permeability. Basically, the gloves can become tacky, and thus do not provide the appropriate dexterity needed during treatment. Water-based lotions are far more compatible with gloves, can be absorbed into the skin more rapidly, and have become increasingly available in both the healthcare and public marketplaces. When deciding which lotion to use, consider the possible interaction of the glove type, dental materials, and antimicrobial hand hygiene products with the lotion.

Question 3. What are some of the common errors that can lead to sterilization failure? 
There are multiple factors that can adversely affect sterilization cycles in an autoclave, dry heat, or unsaturated chemical vapor sterilizer. Problems that apply to each of these heat sterilizers include the following 6 issues:
1. Improper cleaning of instruments. Cleaning is the basic, critical step in instrument processing because it involves removal of contaminating debris and organic material from an instrument before sterilization. If blood, saliva, and other contamination remain, they can shield adherent microorganisms and potentially compromise the sterilization process.
2. Improper packaging. This factor includes using the wrong type of packaging material for method of sterilization, placing too many instruments in a package, and wrapping items in excessive amounts of packing wrap. If the material used to package instruments is not compatible, or excessive wrap is used, the sterilizing agent (ie, moist heat under pressure, dry heat, unsaturated chemical vapor under pressure) may not be able to appropriately contact instrument surfaces, thereby resulting in a sterilization failure. Also, if the packaging material cannot withstand the high temperatures required for dry heat sterilizers, it may melt and create additional problems with the unit.
3. Overloading the sterilizer. Overloading the chamber can result in prolonged warm-up times needed to reach sterilization conditions, and may also prevent thorough contact of the sterilizing agent with all items in the unit. Not spacing wrapped instrument packages adequately is a common problem observed with sterilization failures. Most sterilizers sold in recent years are provided with racks or trays, which allow a maximal capacity of instrument packages and effective sterilization with prescribed cycles. A number of older units can also be fitted with available racks or trays. 
4. Inappropriate sterilization time, temperature, and/or pressure. Issues to consider here include use of inadequate temperature or time during the sterilization cycle and interrupting the total cycle. Human error plays a role here if the sterilizer door is opened during the cycle or timers are incorrectly set, thereby resulting in incomplete sterilization. 
5. Inadequate maintenance of sterilization equipment. Routine maintenance as recommended by the manufacturer is critical to the whole instrument processing protocol. Examples of problem areas here are defective control gauges, which may give erroneous readings of conditions inside the chamber and worn door gaskets and seals. 
6. Use of improper equipment for sterilization. This potential problem is clearly addressed in the CDC Guidelines for Infection Control in Dental Health-Care Settings—2003, with the recommendation: “Use only FDA-cleared medical devices for sterilization and follow the manufacturer’s instructions for correct use.” Neither household ovens nor smaller toaster ovens meet the stringent criteria required in testing and evaluation as heat sterilizers.

Chemical indicators use sensitive chemicals to assess physical conditions (eg, time and temperature) during a sterilization process. Common forms are available as paper strips, labels, and steam pattern cards, which change color when certain temperature, time, and/or pressure conditions are reached during the heat cycle. Since they do not contain bacterial spores as the active agent, chemical indicators are not able to prove that sterilization has been achieved. They are valuable, however, by being able to detect certain malfunctions and can also help to identify procedural errors. Autoclave tape is the historical example of a chemical indicator. It was used for many years as visible proof that items in the chamber had been exposed to a heat sterilization process. Unfortunately, the temperature-sensitive stripes on this tape appear long before sterilizing conditions are reached in the chamber; therefore, this external marker is the least sensitive indicator for heat sterilization.
Recommendations addressing sterilization monitoring continue to include chemical monitoring of cycles. In the comprehensive 2003 CDC guidelines, the following recommendation is made: “Use mechanical, chemical, and biological monitors according to the manufacturer’s instructions to ensure the effectiveness of the sterilization process.” Each load to be sterilized should be monitored with both mechanical and chemical indicators. In a possible event where heat and pressure conditions may not be the same inside and outside the pouch, the guidelines also call for using a chemical indicator on the inside of each package in order to verify that sterilizing vapor has penetrated to reach instruments. A relatively recent innovation has made it easier to accomplish this step. Instrument pouches which contain built-in external and internal multiparameter indicators are now available. Those can provide valuable information to personnel regarding time, temperature, and sufficient exposure of processed instruments to steam.

Question 5. How applicable is “cold sterilization” in today’s world of dental infection control? 
Cold sterilization as related to dentistry refers to the practice of immersion (ie, liquid chemical) disinfection used to reprocess reusable semi-critical instruments or items for patient care. Chemical germicides used in this manner have been either glutaraldehydes, hydrogen peroxide-based, or peracetic acid solutions. There are multiple reasons why chemical immersion sterilization is no longer considered appropriate for reprocessing heat-stable medical instruments. First and foremost, virtually every available reusable dental instrument is heat-stable and should be appropriately cleaned, packaged, and sterilized between uses with a heat-based, biologically monitored process, such as a steam autoclave, dry heat sterilizer, or unsaturated chemical vapor sterilizer. The CDC refers to heat sterilization as the method of choice when sterilizing instruments and devices. If an item is heat sensitive, it is preferable to use a heat-stable alternative or disposable item. While chemical sterilants can sterilize items that would be damaged by heat, the process to accomplish this may require 6 to 10 hours of immersion. Other factors have also precluded the routine use of cold sterilization in current infection control protocols, including: (1) sterilized items must be rinsed with sterile water after removal from the solution in order to remove toxic or irritating chemical residues, and (2) a sterilization process using liquid chemicals cannot be verified by biological, spore test monitors.

Question 6. We are thinking about switching our practice to using cassettes as containers for our instruments. What factors should we consider as we discuss this major step?
The procedural shift away from ungloved healthcare personnel using small scrub brushes to routinely clean contaminated instruments at sinks has been dramatic. As more data have accumulated concerning the potential for personnel to be accidentally stuck with sharp, contaminated instruments, the use of cassettes in hospitals; dental, hygiene, and assisting schools; practices; and other healthcare facilities has increased significantly over the years. A central, precautionary reason for this is the long-standing infection control recommendation that contaminated instruments should be handled carefully, and as little as possible, in order to minimize the occurrence of accidental sharp exposures. Depending on how instruments and packages are handled and subsequently loaded into a sterilizer, there is a potential for personnel to be accidentally stuck with a sharp instrument. Using this concept as a starting point for discussion, the following should be included when discussing incorporation of cassettes into a practice setting:
1. A cassette system can substantially reduce direct handling of contaminated instruments before sterilization.
2. Different cassette sizes are available, whereby they can hold complete sets of instruments for single procedures; this eliminates the need to prepare and process multiple packages.
3. When loaded properly, it is very difficult to overload the cassette; instrument rails or racks inside the cassette are designed to hold a certain number of instruments.
4. Damage to instruments during processing in a cassette can be reduced from that noted with use of bags or pouches, because the items are held more securely in place.
5. Perforated cassettes are preferable over completely solid containers, as the latter may not allow steam or chemical vapor to reach the contents for sterilization to occur.

PPE is designed to protect the skin and the mucous membranes of the eyes, nose, and mouth of dental health-care personnel from exposure to blood or other potentially infectious material. A visible spray is created during the use of rotary dental and surgical instruments (e.g., handpieces, ultrasonic scalers) and air-water syringes. This spray primarily consists of a large-particle spatter of water, saliva, blood, microorganisms, and other debris. Spatter travels only a short distance and settles out quickly, landing either on the floor, nearby equipment and operatory surfaces, dental health-care personnel, or the patient. The spray may also contain some aerosol (i.e., particles of respirable size: 10 microns). Aerosols take considerable energy to generate and are not typically visible to the naked eye. Aerosols can remain airborne for extended periods and can be inhaled. However, they should not be confused with the large-particle spatter that makes up the bulk of the spray from handpieces and ultrasonic scalers. Appropriate work practices such as the use of dental dams and high-velocity air evacuation should minimize droplets, spatter, and aerosols. OSHA mandates that dental health care workers wear gloves, surgical masks, protective eyewear, and protective clothing in specified circumstances to reduce the risk of exposures to bloodborne pathogens.

When should a surgical mask be worn?

Dental health-care personnel should wear a surgical mask that covers both their nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood or body fluids. A surgical mask protects the patient against microorganisms generated by the wearer and also protects dental health care personnel from large-particle droplet spatter that may contain bloodborne pathogens or other infectious microorganisms. When a surgical mask is used, it should be changed between patients or during patient treatment if it becomes wet.

When should protective eyewear be worn?

Dental health care personnel should wear protective eyewear with solid side shields or a face shield during procedures and patient-care activities likely to generate splashes or sprays of blood or body fluids. Protective eyewear protects the mucous membranes of the eyes from contact with microorganisms. Protective eyewear for patients also can protect their eyes from spatter or debris generated during dental procedures. Reusable protective eyewear should be cleaned with soap and water, and when visibly soiled, disinfected between patients.

When should protective clothing be worn?

Various types of protective clothing (e.g., gowns, jackets) are worn to prevent contamination of street clothing and to protect the skin of personnel from exposure to blood and body fluids. When the gown is worn as personal protective equipment (i.e., when spatter and spray of blood, saliva, or other potentially infectious material is anticipated), the sleeves should be long enough to protect the forearms. Protective clothing should be changed daily or sooner if visibly soiled. Personnel should remove protective clothing before leaving the work area.

Why should dental health care personnel wear gloves?

Dental health care personnel wear gloves to prevent contamination of their hands when touching mucous membranes, blood, saliva, or other potentially infectious materials and to reduce the likelihood that microorganisms on their hands will be transmitted to patients during dental patient-care procedures.

Does wearing gloves replace the need for handwashing?

Wearing gloves does not replace the need for handwashing. Personnel should wash their hands immediately before donning gloves. Gloves may have small, unapparent defects or may be torn during use, and hands can become contaminated during removal of gloves. In addition, bacteria can multiply rapidly in moist environments underneath gloves; thus, personnel should dry their hands thoroughly before donning gloves and wash immediately after removing the gloves. If the integrity of a glove is compromised (e.g., if the glove is punctured), the glove should be changed as soon as possible.

Is it safe to wash gloves before use?

Washing of latex gloves with plain soap, chlorhexidine, or alcohol can cause micropunctures. This condition, known as "wicking," may allow liquids to penetrate through undetected holes in the gloves. For that reason, washing of gloves is not recommended.

Are gloves affected by dental materials?

Exposure to glutaraldehyde, hydrogen peroxide, and alcohol preparations may weaken latex, vinyl, nitrile, and other synthetic glove materials. Other chemicals associated with dental materials that may weaken gloves include acrylic monomer, chloroform, orange solvent, eugenol, cavity varnish, acid etch, and dimethacrylates. Because of the diverse selection of dental materials on the market, glove users should consult glove manufacturer about the compatibility of glove material with various chemicals.

Are there different types of gloves?

Yes, there are. The type of glove used should be based upon the type of procedure to be performed (e.g., surgical vs. nonsurgical, housekeeping procedures). Medical-grade nonsterile examination gloves and sterile surgical gloves are medical devices regulated by the U.S. Food and Drug Administration (FDA). General-purpose utility gloves are not regulated by the FDA because they are not promoted for medical use. Sterile surgical gloves must meet standards for sterility assurance established by the FDA and are less likely than nonsterile examination gloves to harbor pathogens that may contaminate an operative wound.

Glove Type Indications Comments Common Glove Materials
Patient examination gloves Examinations and other nonsurgical procedures involving contact with mucous membranes; laboratory procedures Medical device regulated by the FDA.
Nonsterile and sterile, single-use disposable. Use for one patient and discard appropriately.

Monica Symes, a dentist in Lyme Regis, Dorset, says an NHS infection control worker warned her that keeping back issues of Country Life could make her fail health and safety inspections.

The NHS regulator denies such a rule.

The British Dental Association said dentists were being stymied by heavy-handed rules.

Miss Symes, who has practised as a dentist for more than 30 years, says she was also told not to use adhesive putty, such as Blu-Tack, on posters in her waiting room because of "the danger of cross-infection".

Miss Symes said: "She also told me to reupholster the cushions in my waiting room for patients to sit on in plastic rather than fabric.

"It seemed a bit over the top."

The trust that employs the infection control worker said magazines should be in "good condition and free from obvious contamination".

Cleanliness
A spokesman said: "The [primary care trust] PCT’s current advice to NHS dental practice owners is that patient waiting areas should be kept clear of unnecessary clutter to facilitate regular effective cleaning.
Providing magazines in waiting rooms for patients to read is a good way of helping them to relax and can ease the concerns of anxious individual”

Dr John Milne
British Dental Association
"There is no specific requirement for practices to remove magazines within a specified time period; however, practice owners, as part of a cleaning schedule, should ensure that magazines are in good condition and free from obvious contamination. This advice will be kept under review and may be modified in the event of any future community infection outbreaks."

The Care Quality Commission, which regulates dental surgeries to ensure they meet national standards on things like hygiene, said the regulator had never ordered dental surgeries to remove any magazines, nor set any rules about using Blu-Tack.

A spokesman said: "The only time these things would be an issue would be if our inspectors found them being used in such a way as to compromise the safety of someone using the service."

Dr John Milne, chair of the British Dental Association’s General Dental Practice Committee, said: "Patients are at the heart of everything dentists do and cleanliness and hygiene is taken very seriously by dental practices.

"Providing magazines in waiting rooms for patients to read is a good way of helping them to relax and can ease the concerns of anxious individuals. Blu-tack is often used to display posters that reinforce positive oral health messages or advise patients about the care that the practice provides.

"Dentists are not opposed to regulation, but believe that it should be proportionate, cost-effective and non-duplicatory. Too often, in recent years, it has felt like regulation has been designed to hinder, rather than support, dentists’ efforts to care for their patients."