Adams School of Dentistry: Infection Control Manual - Chapter 10: Operatory Infection Control Procedures

Operatory Standard

At the beginning and end of the clinical day, each operatory is considered contaminated. It is the policy of the Adams School of Dentistry (ASOD) that every operatory will receive a double wipe (clean and disinfect) with an intermediate-level disinfectant at the start and end of each clinical sessions, between patients when plastic barriers are not utilized, if equipment surfaces are suspected or confirmed to have been contaminated during treatment, and/or at the discretion of faculty and/or staff. When plastic barriers are utilized and there has been no contamination to surfaces covered by a barrier, only a single wipe (clean) is required, after barriers have been removed.

Clarifying, a “double wipe” is the same as “spray-wipe-spray: or “wipe-discard-wipe” in that surfaces are wiped by removing any bioburden remaining on surfaces, dispose of the cleaning appliance, area is allowed to dry (per manufacturer guidelines), and wiped a second time to disinfect surfaces.

Use of pre-moistened, intermediate-level disinfectants is preferred within ASOD, due to limiting issues caused by over-spray. However, use of a spray bottle that contains the intermediate-level disinfectant and paper towels is an acceptable method, which may be utilized interchangeably as needed. Additional information and definitions on intermediate-level disinfectants may be reviewed on the CDC website.

Armamentarium Availability in Operatories

Each operatory and/or clinical area must have the following armamentarium at a minimum and depending on the clinical area, additional items may be available. Special consideration on item availability may be given based on the ability to secure supplies, planned procedure, recommendations from regulatory or recommendation-based agencies, and/or guidance from the Infection Control Committee.

• Disinfectant wipes / spray
• Disposable gloves
• Patient napkins
• Plastic barriers (STUDENT CLINICS)
  • NOTE: Student clinics are required to utilize plastic barriers. All other clinical areas, review the "Recommended" section below.
• Appropriate type of mask
• Disposable treatment gloves
• Disposable tray covers
• Saliva ejectors
• High-volume evacuation (HVE) tips
• Cotton rolls & gauze
• Protective needle shields/cards
• Marked sharps container
• Liquid hand soap
• Alcohol-based hand sanitizing rub
• Heavy duty gloves

Recommended - Not applicable to Student Clinics:

• Plastic barriers
  • NOTE: If plastic barriers are not utilized in non-student clinics, all equipment must be cleaned and disinfected between patients. Review "Operatory Standard" section of this chapter for more information.

Armamentarium Policy

Disposable barriers should be utilized whenever possible and are required for use in any of the student clinic's, to protect frequently touched surfaces during procedures and difficult to disinfect areas, especially in student clinical areas. One additional benefit is that areas covered by disposable barriers save time in turning-over an operatory, due to areas covered not requiring to be wiped between patients, per US Centers of Disease Control and Prevention guidelines. However, these areas must still receive a double wipe at the beginning of the day, end of the day, when debris is visible under the barrier, the barrier is damaged, or contamination is suspected.

Modification to this policy is permissible depending on the clinical area, procedure to be completed, and availability of supplies. Decisions on this modification are on a case-by-case basis. If plastic barriers are not utilized during clinic setup, all areas uncovered must receive a double wipe between patients, which increases turn over time and availability for patient care.

As of 01/2024, ASOD Pediatric Dentistry clinical areas have been implicitly approved by the Infection Control Committee to not utilize barriers in their clinical sessions. With the exception of the student clinics, all other clinical areas maintain the autonomy to modify this armamentarium policy as needed, provided said changes do not negatively effect patient safety, patient care, operator safety, or student learning.

Operatory Cleaning & Disinfection Standard

Accurate disinfection is achieved by wiping each item/surface once to clean it, allow the item/surface to dry, and wiping it a second time to disinfect. With full Personal Protective Equipment (PPE), clean and disinfect (wipe/discard/wipe) the following areas in the operatory with appropriate intermediate-level disinfectant materials, at a minimum. Review of the video “If Saliva Were Red” provides a visual representation of why specific areas are cleaned and disinfected.

1. Handpiece Control System
   1. Tubing holders
   2. Handpiece tubing
   3. Air/water syringe and tubing
      • Review Chapter 09: Dental Unit Waterlines (DUWL) & Vacuum Maintenance for full procedure. 
   4. Air brake
   5. Delivery tray holder / tray
   6. Chair control pad
   7. Water bottle

2. Dental Light
   1. Handles (2)
   2. Dental light shield (If debris visible, clean with cotton gauze, soap/water, and dry with cotton gauze)

3. Assistant Instrumentation
   1. Tubing holders
   2. Air/water syringe and tubing
      • Review Chapter 09: Dental Unit Waterlines (DUWL) & Vacuum Maintenance for full procedure. 
   3. Suction and tubing
      • Review Chapter 09: Dental Unit Waterlines (DUWL) & Vacuum Maintenance for full procedure. 
   4. Delivery tray holder / tray (If applicable)

4. Dental Patient Chair
   1. Chair arm rests / chair
   2. Chair arm release buttons (If applicable)

5. Operator Stool
   1. Stool adjustment handles
   2. Chair pan, as needed

6. Assistant Stool
   1. Stool adjustment handles
   2. Chair pan, as needed

7. Workstation Area
   1. Work console (drawers, knobs, cabinets, counter top)
   2. Keyboard / mouse (If equipment is able to be wiped)
   3. Patient glasses

Operatory Draping Standard

After cleaning and disinfecting the operatory, and performing appropriate hand hygiene, place disposables and *barriers on the following areas. NOTE: Barriers are required in all student clinics. Barriers are strongly recommended for all other ASOD clinical areas, with the exception of ASOD Pediatric Dentistry.

1. Handpiece Controls
   1. Air/water syringe tip(s)
   2. Barriers

2. Dental Light – Barriers Only
   1. Handles (2)
   2. Switch/button

3. Evacuation Instrumentation
   1. Saliva ejector
   2. HVE
   3. Barriers

4. Dental Patient Chair – Barriers Only
   1. Headrest/back
   2. Armrests (2)
   3. Release buttons (2 - if applicable)

5. Computer Monitor and Keyboard – Barriers Only

6. Operatory Stool - Barriers Only
   1. Back
   2. Adjustment levers and knob

7. Assistant Stool - Barriers Only
   1. Abdomen bar
   2. Adjustment levers and knob

Operatory Setup Procedure

1. Designate one area of the operatory to be considered clean and kept separate for the placement of clinical worksheets, writing instruments, and sterilized equipment. Items in this area should only be handled without gloves, to maintain asepsis. Alternatively, place a barrier on the writing utensil and a clean paper towel over the worksheet upon which to rest the hand when writing.
2. Place two (2) disposable patient napkins, or other clean and disposable item (i.e., sterilization wrap from instrumentation, new paper towel, etc.), on a work surface and retrieve all necessary instruments and supplies for procedure.
3. Place instruments from dispensary or appropriate area on disposable napkins/item and ensure that instruments have been sterilized. Summary of verifying sterilization is completed by reviewing instrument tape and internal indicator has turned dark brown or black for wrapped instruments, or internal/external indicators have turned dark brown or black for packaged instruments. Detailed instructions on sterilization verification may be reviewed in the “Sterilized Instruments in Operatories - Wrapped / Packaged” section.
4. If instruments are found to not be sterilized, return instruments to dispensary or appropriate area, discard of patient napkins/disposable item, put on full PPE, clean and disinfect area/exposed equipment, retrieve new patient napkins, secure new instruments, and repeat the process.
5. Within Student Clinics, set internal indicators of cassettes and paper packaged with indicators to the side of instruments so that faculty and patient can confirm that the instruments were sterilized appropriately.
6. Open sterilized, packaged burs, handpiece, and ultrasonic tips; insert and setup each item.
7. Ensure that handpieces hoses, handpieces, and air/water syringes are securely seated in their holders, with ultrasonic insert tips facing the floor, to reduce the chance of Bloodborne Pathogen (BBP) exposure.

Sterilized Instrument Use in Operatories Standard

All packaged and sterilized instruments must be inspected before use for evidence of sterility. Instruments wrapped in appropriate autoclave wrap will have steam indicator tape securing it to the cassette. Appropriately sterilized, wrapped cassettes will have several dark brown or black lines running through it, which indicates it has been processed through an autoclave. Packaged items will have an internal and external indicator that also turns dark brown or black but is limited to a small space. If neither a wrapped or packaged instrument have these indicators, the instrument is considered to not be sterilized and must not be used. Immediately return the instrument to the appropriate dispensary area or staff, advise of the situation, wipe down any surface area that the instrument has touched, and consider any instruments that were touching the non-sterilized instrument as contaminated, regardless of indicators.

Once sterility of instruments has been confirmed, wrapped cassettes can be carefully removed, making every effort not to tear the wrap or damage the tape. Locate the Steam Monitoring Strip that is placed in the cassette and check to make sure that the indicator has turned dark brown or black, according to manufacturer instructions. After confirming that the strip has changed color, remove it from the cassette and place it next to the unwrapped cassette. Determine if any instruments are missing from the tray and if so, return the cassette to the dispensary area and obtain a new one. For packaged instruments, take care in peeling the packaging open and not bursting or tearing instruments through as this can transfer contaminants to the instruments themselves. Open the packaging so that instruments will fall onto a prepared, clean tray. Determine if any instruments are missing from the tray and if so, return the instruments to the dispensary area and obtain a new one.

Patient Pre-dismissal Procedure

Ensuring the following process is completed before the patient leaves assists in reducing errors, waste, and issues if a BBP exposure were to occur as the patient remains on site.

1. Remove burs and ultrasonic tips from handpieces
2. With appropriate needle shield/hub in place, remove covered needle from anesthetic syringe. Position the card over the opening of the sharps container with sharp side down. Push needle hub through the card and into the container. Review this video example of removal of needle with needle shield for more information.
3. Remove blades from scalpel blade holders with locking hemostat, needle holder, or appropriate device, according to manufacturer guidelines. Review this video example of removing a scalpel blade for more information.
4. Discard anesthetic cartridges, blades, and all other sharps disposal items into designated biohazard sharps containers.
5. Account for all instruments originally found in the instruments pulled, then secure
6. Remove PPE in appropriate order, drape gown over operator chair or hang it up, perform hand hygiene, and escort patient to the front desk.

Patient Post-dismissal Procedure

Adhering to the same methodology as earlier, clean and disinfect the operatory (wipe/discard/wipe) with an appropriate intermediate-level disinfectant, with teardown instruction below:

1. Put on a new set of heavy-duty, disposable gloves
2. Invert plastic dental chair cover and invert, so that it can be used to collect discarded all non-sharp, disposable items. When finished, discard bag into a biohazard receptacle.
   • In clinical areas that opt to not utilize plastic barriers, all single use items must be disposed of within a biohazard receptacle.
   • Student clinics are required to utilize plastic barriers and are expected to follow the following steps.
3. Remove handpiece(s), wipe with disinfectant, and place to the side with contaminated instruments
4. Transport contaminated instruments and handpieces to the decontamination area. Specific area depends on clinical area but should be labeled area
5. Return to operatory, remove heavy-duty gloves, and put on a new set of disposable gloves. Clean and disinfect same areas as listed earlier.
6. All non-critical, multiple use items and equipment are to be cleaned and disinfected (wipe/discard/wipe) before being returned to drawers or dispensary areas
7. Remove PPE and perform appropriate hand hygiene
8. If treatment is to be provided to new patient on the same clinic day, place disposables and barriers as directed earlier.

Operatory End of Day Standard

When the end of the clinical day has been reached, clean and disinfect the operatory as described above, including flushing waterlines (Review Chapter 09: Dental Unit Waterlines (DUWL) & Vacuum Maintenance for full procedure). Additional steps include:

1. Raise dental chair to its highest position and turn off main switch
2. Perform appropriate hand hygiene

Personal Items in the Operatory

Dental operatories are considered a treatment area and for the safety of the operator and to minimize chances of cross-contamination, the operatory must not contain personal items. In this instance, personal items can be considered, but are not limited to, backpacks, purses, pictures (except for the display of current licenses), and other items that are not related to treatment. Personal items can interfere with the flow of patient, provider, and/or faculty access and egress from operatories, thus creating a safety concern related to trips and falls. Person items also collect aerosols and spatter, many of which cannot be appropriately disinfected and can lead to cross-contamination of multiple personal items.

Limited use of personal cell phones is permitted in operatories, provided that it is not utilized for personal use and is kept in a drawer or pocket when not actively being utilized. Generally, cell phones are allowed without gloves, after performing hand hygiene, and during treatment for language interpretation, meditation apps/music to calm patients, and for medical emergencies. Using personal cell phones can lead to potential contamination and should be minimized as much as possible, while also periodically being disinfected.

Contamination Prevention & Personal Items Standard

Only items and surfaces that have been appropriately cleaned and disinfected and/or sterilized constitute the patient’s “chain of asepsis.” Cross-contamination should always be minimized by limiting contact with objects such as, but not limited to, keyboards, mouse, telephone, cabinet, and dropped instruments during procedures. If the “chain of asepsis” is broken for any reason, gloves must be removed, hand hygiene performed, and a new set of gloves put on. Some examples of this would include moving a dropped instrument, retrieving material/instruments, or utilizing items in clean areas.

Before accessing any clean area, including but not limited to inside drawers, consumable containers, clean areas, or leaving operatories, doffing gloves and performing hand hygiene is required. If the operatory was left, the operator must perform hand hygiene and put on gloves upon re-entry.

Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood for occupational exposure. Food and beverages are only to be consumed by ASOD personnel in safe, designated areas, which do not include countertops or bench tops where blood or other potentially infectious materials may be present.

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Proceed to Chapter 11