INFECTION CONTROL LECTURE | DR.

KENNY DEAN ARDAÑA

CHAPTER 13: SURFACE AND EQUIPMENT

ASEPSIS
FINALS

CHAPTER 13: SURFACE AND EQUIPMENT ASEPSIS

OUTLINE
I Types of Environmental Surfaces
II Surface Covers
A Types of Surface Covers
B Use of Surface Covers
III Precleaning and Disinfection
A Approaches to Precleaning and Disinfection
B Characteristics of Disinfectants
IV Equipment Decontamination
A General Considerations
B Management of High – tech equipment
V Aseptic Distribution of Dental Supplies
A Aseptic Retrieval
B Unit Dosing

o clear plastic wrap

TYPES OF ENVIRONMENTAL SURFACES o bags or tubes
o plastic-backed paper
CLINICAL CONTACT SURFACES  Some plastics are designed specifically for use as
 are surfaces that may be touched frequently with surface covers in the office in that they have the
gloved hands during patient care or that may become shape of the item to be covered (e.g., air/water
contaminated with blood, saliva, or other potentially syringe handle covers, hose covers, and pen covers).
infectious material and subsequently contact  Some sheets of plastic also have a slightly sticky
instruments, devices, hands, or gloves. substance on one side to hold them on the surface.
 The clinical contact surfaces need to be treated Other plastics (e.g., some food wraps) have a natural
properly before they become involved in the care of clinging ability on contact with a smooth surface
the next patient.  Some plastic bags are available with drawstrings that
HOUSEKEEPING SURFACES hold the bag around an item to be protected.
 are surfaces that do not come into contact with hands EXAMPLES OF SURFACES SUSCEPTIBLE TO
or devices used in dental procedures (e.g., floors, CONTAMINATION DURING PATIENT CARE
walls, and sinks). ACTIVITIES
 Housekeeping surfaces can be treated at the end of  Air/water syringe handle
the day.  Air/water syringe hoses
 Consequently, if a surface becomes contaminated  Bracket table Chair control buttons
with saliva, blood, or other potentially infectious  Countertops Dental team chair backs
material, the safest approach is to assume that it,  Drawer handles Evacuator control
indeed, contains live microorganisms that must be  Evacuator hoses
removed or killed before the surface is involved in the  Faucet handles
treatment of the next patient.  Handpiece control switches
TWO GENERAL APPROACHES TO SURFACE ASEPSIS  Handpiece hoses
ARE THESE:  Headrest on chair
 One is to prevent the surface or item from becoming  Light curing handle and tip
contaminated by use of a surface cover, and the other  Light handles
is to preclean and disinfect the surface after  Light switch
contamination and before reuse  Mirror handles
SURFACE COVERS  Shade guides
 Supply containers and bottles
TYPES OF SURFACE COVERS  X-ray unit controls
 X-ray unit handle and cone
 Surface covers should be impervious to fluids to  X-ray view box switch
keep microorganisms in saliva, blood, or other liquids
from soaking through to contact the surface. USE OF SURFACE COVERS
 Examples of appropriate material for surface covers
include:
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CHAPTER 13: SURFACE AND EQUIPMENT ASEPSIS
 Dental units come in several shapes and sizes with hoses can be covered and secured with rubber
different positioning of the handpiece control system bands.
and light and other accessories.  Covering the air/water syringe handle with plastic
 Thus, the sizes and shapes of surfaces to be covered wrap to prevent contamination is better than trying to
vary from one office to the next, but general preclean and disinfect properly around the buttons
procedures for use of surface covers are the same. that tend to retain debris.
 Some lights have removable handles that can be
cleaned and heat sterilized before reuse. One can
cover the heads of x-ray units and the control panels,
and if the water at sinks is not controlled by elbow
levers, foot pedals, or automatic devices, one can
cover faucet handles with plastic bags.

Table No.1 Surface Covers Versus Precleaning and

Disinfection
Advantages Disadvantages PRECLEANING AND DISINFECTION
Surface Covers  Precleaning and disinfection best lend themselves
 Protects surfaces that  A variety of appropriate to nonelectric surfaces that are smooth and easily
are difficult to preclean sizes and types may be accessible for facilitating good contact with the
adequately. needed. decontaminating chemicals.
 May be less time –  Adds nonbiodegradable
consuming to perform plastic to the environment APPROACHES TO PRECLEANING AND DISINFECTION
 Reduces handling and on disposal.  Precleaning reduces the number of contaminating
storing of disinfecting  May be esthetically microorganisms and the blood or saliva present
chemicals unattractive (referred to as bioburden) and facilitates action of the
 May be more expensive disinfecting chemical
than precleaning and  Use a disinfectant for both the precleaning step and
disinfection the disinfecting step. Using a disinfectant for the
Precleaning and Disinfection precleaning step starts the killing process early and
 Requires purchase of  Time-consuming when reduces the chances of spreading the contamination
fewer items to accomplish performed properly. to adjacent surfaces.
surface asepsis.  Must use personal
 May be less expensive protective barriers to
than using surface covers. protect against contact TWO APPROACHES TO PRECLEANING AND
 Does not change the with the chemicals. DISINFECTION
esthetic appearance of the  Cannot verify whether the SPRAY-WIPE-SPRAY
office. microbes have been  spray the cleaner/disinfectant on the surface and wipe
 Does not add plastic to the removed or killed. (preclean) the surface vigorously with a paper towel
environment.  Some surfaces cannot be or gauze pad.
precleaned adequately.  Then respray the disinfectant/cleaner on the
 Some chemicals may precleaned surface and let it remain moist for the
damage some surfaces longest contact time indicated on the disinfectant label
 Use of the chemicals (usually 10 minutes).
requires proper material  If moisture remains, one should wipe it away with a
safety data sheets to be paper towel. Some disinfectants are promoted as
on file in office. “one-step” products (i.e., spray and wipe).
 Use-containers must be  The two-step procedure becomes even more
labeled properly Some important should the post cleaning disinfecting
disinfectants must be contact time stated on the product label be shortened
prepared fresh daily for some reason.
 Chemicals are added to  Do not store paper towels or gauze pads in a
the environment on disinfectant and use as wipes to avoid spraying.
disposal.  Wet the towels or pads just before use. Paper towels
 Clear plastic bags are available in various sizes and may be held behind some surfaces to catch
are easy to use. For example, if a chair has control overspray, if desired.
buttons on the side, one can use one bag to cover the WIPE – DISCARD – WIPE
headrest and the buttons. It’s really not necessary to
cover the entire dental chair for most of chair (save  Pull a towelette from its container and wipe (preclean)
the arm rests) is covered with the patient’s body. the surface. Then discard that towelette.
 Wraparound backs of side chairs used by the dental  Obtain another towelette and wipe (disinfect) the
team may be touched during patient care and can be surface, let the surface remain wet for the prescribed
covered with a large plastic bag. time, and discard the towelette. Dry off the surface if
 The bracket table is easily covered, and the necessary.
handpiece and air/water syringe connectors and  When using containers of disinfectant towelettes,
keep the lid closed when not in use to prevent
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CHAPTER 13: SURFACE AND EQUIPMENT ASEPSIS
evaporation of the alcohol. Also, periodically invert the  These classes are identified by the type of
container to redistribute any settled liquid. antimicrobial agents present in the product, which are
CHARACTERISTICS OF DISINFECTANTS listed on the product label as active ingredients.
 Because M. tuberculosis var. bovis is more difficult to
THERE ARE FOUR GENERAL TYPES OF kill than most other microorganisms, disinfectants
with tuberculocidal activity are considered as
ANTIMICROBIAL CHEMICALS:
strong disinfectants.
 Antibiotics (for killing microorganisms in or on the  Stronger disinfectants are active against
body) nonenveloped hydrophilic viruses.
 Antiseptics (for killing microorganisms on the skin or  Use of a water-based disinfectant is reported to
other body surfaces) provide better cleaning of biological material, such as
 Disinfectants (for killing microorganism blood, than use of an alcohol-based disinfectant.
 Sterilants (for killing all microorganisms on inanimate  For dental infection control, a water-based surface
objects) disinfectant that is Environmental Protection Agency
 The Centers for Disease Control and Prevention has (EPA)-registered and tuberculocidal (such as
categorized disinfectants based on their microbial iodophors, phenolics, or chlorines) is appropriate if
spectrum of activity. used as directed by the manufacturer and careful
o Sterilant/ high-level disinfectant (for killing precleaning is performed.
all microorganisms on submerged,  The U.S. Food and Drug Administration also must
inanimate, heat sensitive objects) grant marketing clearance to liquid chemical
sterilants/high-level disinfectants labeled for use on
o Intermediate-level disinfectant (for killing medical devices, such as heat-sensitive dental items.
vegetative bacteria, most fungi, viruses, and
M. tuberculosis var. bovis)
o Low-level disinfectant (for killing most Table No.2 Categories of Disinfecting/ Sterilizing Chemicals
vegetative bacteria, some fungi, and some
viruses) Category Definition Examples Use
 Labels on antimicrobial products can be confusing but Sterilant Destroys all Glutaraldehyde, Heat-
microorganisms, glutaraldehyde sensitive
reading these labels carefully before using the including high phenate, hydrogen reusable
product is very important. These labels commonly numbers of peroxide, hydrogen items:
include the type of antimicrobial agent (active bacterial spores peroxide with immersion
ingredients) and general properties such as the peracetic acid, only
following: peracetic acid
High-level Destroys all Glutaraldehyde, Heat-
o Virucidal (kills at least some viruses) disinfectant microorganisms, glutaraldehyde sensitive
o Bactericidal (kills at least some bacteria) but not phenate, hydrogen reusable
o Fungicidal (kills at least some fungi) necessarily high peroxide, hydrogen items:
o Tuberculocidal (kills the M. tuberculosis numbers of peroxide with immersion
bacterial spores peracetic acid, only
var. bovis bacterium) peracetic acid,
o Sporicidal (kills bacterial spores, which orthophthalaldehyde
means it is a sterilant) Intermediat Destroys EPA-registered Clinical
o Hospital disinfectant (shown to kill the three e-level vegetative hospital disinfectant† contact
disinfectant bacteria, most with label claim of surfaces;
representative bacteria: Staphylococcus fungi, and most tuberculocidal activity noncritical
aureus, Salmonella choleraesuis, and viruses; (e.g., chlorine-based surfaces
Pseudomonas aeruginosa) inactivates products, phenolics, with visible
 The labels also commonly include the following: Mycobacterium iodophors, quaternary blood
tuberculosis var. ammonium
o Specific microorganisms (genus and
bovis (is compounds with
species) shown to be killed in laboratory tuberculocidal) alcohol, bromides)
testing (along with the necessary contact Low-level Destroys EPA-registered House –
time) disinfectant vegetative hospital disinfectant keeping
o Directions for use of the product, including bacteria, some with no label claim of surfaces
fungi, and some tuberculocidal activity (e.g.,
the need for precleaning viruses; does not (e.g., quaternary floors,
o Precautionary statements on handling the inactivate M. ammonium walls);
product. tuberculosis var. compounds) noncritical
o Warnings such as toxic, poisonous, or bovis (is not surfaces
tuberculocidal) without
flammable Treatment for accidental contact visible
o Storage and disposal information blood;
o Shelf-life and use-life clinical
o How to activate or dilute the product contact
surfaces‡
o Name and address of the
manufacturer/distributor, volume of the
container, and Environmental Protection
Table No.3 Active Ingredients in Surface Disinfectants
Agency (EPA) registration number Types of Disinfectant Example of Active Ingredient(s)
 Several classes of disinfecting chemicals have gained Listed on Product Label
wide use in dentistry and medicine. Chlorines Sodium hypochlorite
Iodophors Chlorine dioxide
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CHAPTER 13: SURFACE AND EQUIPMENT ASEPSIS
Water – based phenolics Butoxypolypropoxypolyethoxy- skin, although alcohol does “sting” when placed on
ethanol-iodine complex mucosa (e.g., eye, mouth, and nostrils).
Triphenolics o-Phenylphenol, o-benzyl-p-
chlorophenol, and tertiary
 Alcohols at 50% to 70% concentration rapidly kill
amylphenol many microorganisms and are tuberculocidal, they
Dual phenolics o-Phenylphenol and o-benzyl-p- evaporate rapidly when sprayed or wiped on surfaces.
chlorophenol  Alcohol has other properties that make it less
PCMX p-Chloro-m-xylenol desirable than other agents as a disinfectant.
Alcohol – based phenolics Ethyl or isopropyl alcohol plus
 Alcohols also do not solubilize protein material in
o-Phenylphenol or o-phenylphenol
and tertiary amylphenol blood or saliva well and have been reported to be
Alcohols Ethyl alcohol, isopropyl alcohol poor cleaners.
Quaternary ammonium  Alcohols dry out the skin because they tend to
compounds† dissolve fat and oil that serve as natural skin
First Generation Benzalkonium chloride moisteners. The “waterless” alcohol-containing hand
Second Generation Alkyldimethylethylbenzyl
ammonium chloride or alkyl-
rubs also contain special skin moisteners to reduce
dimethyl-3,4-dichloro-benzyl these drying effects.
ammonium chloride
Third Generation Combination of first and second SYNTHETIC PHENOLICS
generation
Fourth Generation Dioctyldimethyl ammonium  Phenol (also known as carbolic acid) has the
bromide or didecyldimethyl distinction of being the first widely recognized
ammonium bromide disinfectant used in hospitals.
Fifth Generation Combination of first and fourth  Lord Joseph Lister suggested the use of phenol as
generation
Alcohol–quaternary ammonium A dimethyl-benzyl ammonium
an antiseptic during surgical procedures and as an
compound chloride plus isopropyl alcohol environmental surface disinfectant more than 100
years ago.
 Several phenol-related (phenolic) compounds have
CHLORINE COMPOUNDS
been synthesized since and used for microbial killing.
 Chlorine compounds have been used for many years Thus, these compounds are referred to as synthetic
to disinfect drinking water, swimming pool water, and phenolics, with some use today as active ingredients
various inanimate surfaces. in surface disinfectants and in mouth rinses and
 These agents are intermediate-level disinfectants, kill handwashing agents.
a wide variety of microorganisms, and are  Most of the synthetic phenolic disinfectants are
tuberculocidal. intermediate level tuberculocidal agents and may
 Sodium hypochlorite (which is the main chemical in contain one, two (dual phenolics), or three phenolics
bleach) is an example of a chlorine compound used to (triphenolics), as well as detergents to facilitate
disinfect surfaces. cleaning.
 One should note that commercial bleach (which QUATERNARY AMMONIUM COMPOUNDS
contains approximately 5.25% sodium hypochlorite) is
a good surface disinfectant at a 1:10 to 1:100 dilution
with water, even though the bleach product is not an  Alcohol-free quaternary ammonium compounds
EPA-registered disinfectant. o Quaternary ammonium compounds are also
 Sodium hypochlorite can damage fabrics and metal called “quats”. These compounds are
surfaces (particularly aluminum), and its activity is cationic detergents categorized as low-level
reduced in the presence of organic material. disinfectants.
o All of the alcohol-free quat disinfectants have
IODOPHORS
a low level of antimicrobial activity, and none
 Iodine and iodine-alcohol mixtures (known as are tuberculocidal. These disinfectants also
tinctures of iodine) are well-known killing agents but may be inactivated by organic materials and
have some undesirable properties of corrosiveness, soaps.
staining, irritation of tissues, and allergenicity.  Quaternary ammonium compounds with alcohol
 Most iodophors are intermediate level disinfectants o The addition of alcohol to quaternary
and retain the broad-spectrum antimicrobial activity ammonium compounds by manufacturers
(including tuberculocidal activity) of iodine, but they enhances their antimicrobial activity. These
are less corrosive, are less irritating to tissues, and intermediate-level disinfectants are
have reduced staining activity. tuberculocidal and are appropriate for use in
 Detergents are added to iodophor preparations used dentistry.
as surface disinfectants to enhance the cleaning
ability of the solution. EQUIPMENT DECONTAMINATION
 Iodophors still may be slightly corrosive to some
metals and may cause slight staining with repeated GENERAL CONSIDERATIONS
use on light-colored surfaces
ALCOHOLS  In general, one should try to prevent the equipment
 Isopropyl alcohol (isopropanol, sometimes referred to from becoming contaminated in the first place.
as rubbing alcohol) and ethyl alcohol (ethanol) have  One should use the following principles to reduce the
been used as antiseptics and disinfectants for many spread of microbes from dental equipment used in the
years because they are relatively nonirritating to the mouth that will penetrate soft tissue or tooth structure:
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o If the item is disposable, one should dispose DIGITAL RADIOGRAPHY EQUIPMENT
of it properly after use on one patient.  needs special attention. This equipment uses intraoral
o If the item is not disposable, one should sensors to provide a digital image that can be
clean it, package it, and heat sterilize it. manipulated, viewed on a monitor, printed, or stored
 One should use the following approach to electronically.
decontamination if the item will be used in the  Because the sensors are reusable, one must handle
patient’s mouth but will not penetrate soft tissue or them properly to prevent cross contamination during
tooth structure: subsequent use. One type of sensor, the charge-
o If the item is disposable, one should dispose coupled device (CCD), is attached to a wire and
of it properly after use on one patient. should not be heat sterilized.
o If the item is reusable, one should cover the  Instead, one should cover the CCD with a plastic
parts that may become contaminated with an barrier that extends down the cable to prevent any
impervious barrier to prevent contamination. contact with patient materials or contaminated hands.
o If the item is not disposable, cannot be  Another type of digital x-ray sensor is the
covered completely, and becomes complementary metal-oxide semiconductor with
contaminated, one should clean it, package active pixel sensors. This device is wired and should
it, and heat sterilize it. be treated with plastic barriers just like the CCD
o If the item cannot be heat sterilized, one sensor.
should clean and submerge it in a liquid  A third type of sensor, the photostimulable
sterilant/high-level disinfectant. phosphor plate sensor, is wireless and is placed in
o If the item is not disposable and cannot be the patient’s mouth much like a regular film packet.
covered, heat sterilized, or submerged in a One must cover the device with a plastic barrier; it
liquid agent, do not use the item. cannot become contaminated because it cannot be
 One should use the following approach for items that heat sterilized or chemically disinfected, to mention
are not used in the patient’s mouth: only a few.
o If an item will not become contaminated with
patient materials, one should just keep it ASEPTIC RETRIEVAL
clean.
o If an item will become contaminated with
 One must use an aseptic retrieval system (rather than
patient materials, one should clean it and, saliva-coated gloved fingers) to avoid contamination
when possible, heat sterilize it. of unused items in the container.
o If the item cannot be heat sterilized because
UNIT DOSING
of its size or composition, one should clean
and disinfect it.
 Some supply items are unit dosed by the
manufacturers, saving office staff time. Although unit
MANAGEMENT OF HIGH-TECH EQUIPMENT dosing can solve some cross-contamination
COMPUTERS problems, unfortunately it can be expensive and
 one should avoid their contamination by performing wasteful if not organized properly.
hand hygiene before use. If this does not occur,
recent studies have shown that the keyboards can be
successfully decontaminated by using disinfectant
wipes such as those containing quaternary
ammonium compounds.
35 MM, VIDEO, AND DIGITAL CAMERAS,
 one should try to avoid their contamination. They are
not designed to be disinfected. One should cover
them with plastic sheeting or operate them only with
clean hands.
COMPUTER-AIDED DESIGN/COMPUTER-AIDED
MANUFACTURING DEVICES (CAD/CAMS)
 use close-up intraoral pictures to design and
manufacture restorations.
 These devices use a small camera lens on the end of
a wire that transmits pictures from the patient’s mouth
to a TV-type monitor.
 One should check with the manufacturer for proper
decontamination of the camera and wire.
 One model has an outer removable prismatic device
that slides over the camera lens, so the prism rather
than the camera lens becomes contaminated.
 The prism can be sterilized in a dry heat sterilizer
but not in a steam sterilizer, for the moist heat can
damage the prism.
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