infection control in dentistry and protocols to be followed by dentists in the present situation of COVID 19

1. IN PROSTHODONTICS
Dr. Kaumudhi Kalla
I st YR PG
Department of Prosthodontics

2. CONTENTS
• Introduction
• Terminology
• COVID - 19
• Transmission of diseases
• Principles of infection control
• Objectives of infection control
• ICMR protocols against COVID - 19
• Standard precautions (CDC)
• Procedures of infection control
• Clinical waste disposal
• Conclusion

3. Introduction
• Dentistry is a field that involves the clinician
and the patient being exposed to saliva and
other infectious material.
• Prosthodontic patients are generally a high risk
group relative to their potiential to transmit
infectious diseases as well as acquire them.

4. • The prosthodontists are at an added risk of
transmission because of the infection
spreading through the contaminated lab
equipments while working in the lab.
• Therefore infection control is an important
concept in the present day dentistry which has
to be followed in the clinics as well as in the
laboratory.

5. Terminology
INFECTION CONTROL
Also called “exposure control plan” by Occupational Safety
and Health Administration is a required office program that is
designed to protect personnel against risks of exposure to
infection.
EXPOSURE
is defined as specific eye, mouth, other mucous membrane,
non intact skin, or parenteral contact with blood or other
potentially infectious materials.

6. STERILIZATION :
It is defined as the process by which an article,
surface is freed of all living organisms either in
vegetative or spore form.
DISINFECTION:
Destruction of pathogenic and other kinds of
microorganisms by physical or chemical
means.

7. COVID 19
• COVID 19: CO-corona ,VI-virus, D-disease in
2019
• The definition of coronavirus includes a
range of respiratory viruses, which can
present with mild to severe manifestations
and lead to respiratory failure
• Corona virus term was coined in 1968

8. • This novel coronavirus has zoonotic nature.
• As the genome sequence for this novel coronavirus has a close resemblance
with other beta-coronaviruses such as SARS-CoV and MERS-CoV, the
Coronavirus Study Group of the International Committee on Taxonomy of
Viruses(ICTV) has given it the scientific name SARS-CoV-2, even though
it is popularly called the COVID-19 virus.
• On January 9, 2020, the World Health Organization declared the discovery
a new coronavirus, first called 2019-nCoV and then officially named
SARS-CoV-2.
• On January 30, 2020, the World Health Organization (WHO) declared the
rampant spread of SARS-CoV-2 and its associated disease (COVID-19) a
public health emergency with a currently known overall mortality rate to be
as high as 3.4%.
• On February 11, the respiratory disease deriving from SARS-CoV-2
infection was named COVID-19

10. PATHOGENESIS OF COVID 19

14. Transmission of diseases
• Disease transfer to the dentist and dental staff during
dental care is considered an “ occupational
exposure” to a given pathogen on the other side the
disease may also be transmitted from the dentist to
the patient as well as from one patient to the other.
• The disease transfer from one patient to another in
the dental clinics is considered as “ cross infection”.
• Infection control is aimed to prevent such type of
transmissions in the dental office.

17. • The dental professional must assume that
every patient treated is a risk of cross infection
and to adopt appropriate control measure.

18. Pathway of
cross
contaminat
ion
Source of
micro
organism
Mode of
disease
spread
Site of
entry into
body
Infection
control
procedure
Patient to
Dental team
Patients
mouth
Direct
contact
Breaks in skin Gloves/Hand
washing ,
Immunization
Droplet
infection
Inhalation by
dental team
Protective
clothing , face
shield
Through break in
skin of dental team
Dental
team to
Patient
Dental
team
hands
Direct
contact
Through mucosal
surfaces of Patients
Glove/ hand washing
immunization
Indirect
contact
Blood on items
used on Patients
Instrument
sterilization
Surface disinfection
Droplet
Infection
Inhalation by
patients
Mask
Face shield

19. Path ways of
cross
contamination
Source of
Microorganism
s
Mode of
disease
spread
Site of entry
in to the
body
Infection
Control
procedure
Patient to
Patient
Patient to
mouth
Indirect
contact
Through
mucosal
surfaces of
patients
Immunization
and hand
piece
sterilization
Office to
Community
Patients
mouth
Indirect
contact
Cuts in skin
Waste
disposal
Waste
management
disinfection of
impressions
Dental
teams
families
Dental
teams
body
Fluids
Dire ct or
Indirect
contact
Intimate
contact
management
of laundry
immunization

22. • Based on the article in DCNA 1996, 5 classes
of risk have been described based on the level
of risk and case of prevention.

23. PRINCIPLES OF INFECTION CONTROL
• PRINCIPLE 1- STAY HEALTHY
• PRINCIPLE 2- AVOID CONTACT WITH BLOOD
• PRINCIPLE 3- LIMIT THE SPREAD OF BLOOD
• PRINCIPLE 4- MAKE OBJECTS SAFE FOR USE
• PRINCIPLE 5- PATIENT SCREENING

24. Reduce
Implement
Simplify
Protect
OBJECTIVES OF INFECTION CONTROL

25. ICMR Protocol
against Corona
Preparatory
Phase(I)
Implementation
Phase(II)
Follow up (III)
MAY 19, 2020

26. Preparatory Phase(I)
• Doctor and health care
prophylaxis against COVID-
19
• Testing for COVID -19
before resuming work in
clinics
• Equipment and
instrumentation
• Use of N- 95 masks
• Standard precautions
• Sterilization and disinfection
Implementation
Phase(II)
• Tele – consultation, tele –
screening
• Dental history and remote
triage
• Protocol of handling patient
in clinic area
• Patient discharge protocol
• Biomedical waste
management
Follow
up (III)
• Patient
follow
up and
review

27. Centres for Disease control and Prevention
(CDC)
STANDARD PRECAUTIONS include —
• Hand hygiene.
• Use of personal protective equipment (e.g., gloves,
masks, eyewear).
• Respiratory hygiene / cough etiquette.
• Sharps safety (engineering and work practice controls).
• Safe injection practices (i.e., aseptic technique for
parenteral medications).
• Sterile instruments and devices.
• Clean and disinfected environmental surfaces.

28. Infection control procedures
• There are some procedures in infection control which are to
be followed strictly to prevent any cross contamination.
• The main emphasis should not be only on patient protection
but also on protection of the dental team.
The procedures involve:
1. Patient screening
2. Personal hygiene
3. Personal protection
4. Instrument processing
5. Surface asepsis
6. Patient treatment
7. Laboratory disinfection

29. Patient screening
• Any treatment has to be performed only after a
comprehensive patient evaluation.
• This is generally accomplished by recording
medical history specially designed to identify
the patients who are either particularly
susceptible to infection or who are at risk of
transmitting infection, known as carriers of
disease or by being in a high-risk category.

30. List of Emergency and Urgent Dental Procedures
• The clinical conditions of dental origin, which require
priority care but do not increase the patient’s death risk
are categorised as URGENT and which increase the
patient’s death risk are categorised as EMERGENCY

31. Emergency Dental Procedures
Clinical condition/ Procedures Risk Level
Fast spreading infections of facial spaces/Ludwig Angina/Acute
cellulitis of dental origin/Acute Trismus.
Should connect with hospital settings emergency settings
immediately.
Very high
Uncontrolled bleeding of dental origin.
Should connect with hospital settings emergency settings to rule
out other causes.
Very high
Severe uncontrolled dental pain, not responding to routine
measures
High
Trauma involving the face or facial bones. Very High
Radiographs like PNS, OPG, CBCT in facial trauma and in
medico-legal situations
High

32. Urgent Procedures
Clinical condition/ Procedures Risk Level
Dental pain of pulpal origin not controlled by Advice, Analgesics,
Antibiotics (AAA)
Repair of Broken complete dentures
Implant prosthesis related issues
Oral mucosal infections such as candidiasis
Already prepared teeth/ implant abutments to receive crowns
Peri-implant infections endangering stability
High
Broken restoration/ fixed prosthesis causing sensitivity of vital teeth/
endangering to pulpitis /significant difficulty in mastication
High
Unavoidable Dental Extractions / Post extraction complications Very High
Dental treatment for patients requiring cardiac surgery
Patients requiring dental treatment for radiotherapy /organ transplantation
Very High
Sharp teeth /Trigeminal neuralgia Moderate

33. • Tele-consult Tele-screening
I. Current medical history and past history particularly
pertaining to symptoms of Severe Acute Respiratory
Illness (fever AND cough and/or shortness of breath) or
All symptomatic ILI (fever, cough, sore throat, runny
nose) must be analysed.
II. Any positive responses to either of the questions should
raise concern, and care should be postponed for 3weeks
except in dental emergencies.
III. Encourage all to download the Arogya Setu App.

34. COVID – 19 Screening Questionnaire
In the past 14 days have you or any household member travelled to areas of known
cases of COVID- 19 ?
In the past 14 days have you or any household member had an contact with a known
COVID – 19 patient?
Have you or any household member have a history of exposure to COVID – 19
biologic material?
Have you had any history of fever in the last 14 days?
Have you had any symptoms such as cough, difficulty in breathing, diarrhea, nausea,
loss of smell, or loss of taste in the last 14 days ?
Urgent dental need question
Do you have any uncontrolled dental or oral pain, infection or swelling or bleeding or
trauma to your mouth?

35. • Dental history and remote TRIAGE
I. Obtain m Oral Health(Mobile Phone-based Oral Health) screening
about dental history and try to manage problems with advice and
analgesics and local measures.
II. Clinics can evolve a web-based form which can also include a
consent form.
III. Comprehend dental treatment according to the urgency of the
required treatment and the risk and benefit associated with each
treatment.
IV. Only pre-appointed patients should be entertained in the clinic
whose history, problems and procedures are already identified to
some extent through previous telephone and remote electronic or
web-based systems.

36. An overview of patient screening for COVID-19
and dental management

37. What can patients do before arrival at a dental clinic?

38. Personal hygiene
Hand Washing
• Hand hygiene (e.g., hand washing, hand
antisepsis, or surgical hand antisepsis)
considered the single most critical measure for
reducing the risk of transmitting organisms.
• Fingernails are kept clean and short to prevent
perforation of gloves and accumulation of
debris.

39. Method Agent Purpose Duration
(minimum)
Indication
Routine
handwash
Water and
nonantimicrobial soap
(e.g., plain soap)
Remove soil and
transient
microorganisms
15 seconds Before and after
treating each patient
(e.g., before glove
placement and after
glove removal). After
barehanded touching of
inanimate objects likely
to be contaminated by
blood or saliva. Before
leaving the dental
operatory or the dental
laboratory. Before
regloving after
removing gloves that
are torn, cut, or
punctured.
Antiseptic
handwash
Water and antimicrobial
soap (e.g., chlorhexidine,
iodine and iodophors,
chloroxylenol [PCMX],
triclosan)
Remove or destroy
transient
microorganisms
and reduce resident
flora
15 seconds
Antiseptic
hand rub
Alcohol-based hand rub Remove or destroy
transient
microorganisms
and reduce resident
flora
Rub hands until
the agent is dry
Surgical
antisepsis
Water and antimicrobial soap
(e.g., chlorhexidine, iodine
and iodophors,chloroxylenol,
triclosan)
Water and non-antimicrobial
soap (e.g., plain soap)
followed by an alcohol-based
surgical hand-scrub product
with persistent activity
Remove or destroy
transient
microorganisms
and reduce resident
flora (persistent
effect)
2–6 minutes
Follow
manufacturer
instructions for
surgical hand-
scrub product with
persistent activity
Before donning sterile
surgeon’s gloves for
surgical procedures

43. Personal protection
• Residents are required to have current immunizations
against communicable diseases including hepatitis B.
• The vaccination programme must certainly be
considered the most effective cross infection control
measure to protect dental personnel and in turn their
patients from a potentially fatal disease.
• In June 1982, council on dental therapeutics adopted a
resolution recommending that all dental personnel
having patient contact including dentists, dental
students and dental auxillary personnel , and all dental
laboratory personnel receive the hepatitis B vaccine.

44. • Doctor and health care prophylaxis against COVID
19.
• Testing for the Covid-19 before resuming work in
the clinics:
• Health care workers who are asymptomatic and do not
fall under the category of being exposed to corona virus
infection are not required to undergo a test before
resuming to work in the clinics.
Hydroxychloroquine prophylaxis
• As per the advisory given by the MOHFW dated
22.03.2020, all asymptomatic healthcare workers
involved in the care of suspected or confirmed cases of
COVID – 19 are advised to take HCQ prophylaxis after
medical consultation.

46. Head cap
• Hair should be neatly tied back and kept out of
treatment field and should be covered with head cap to
avoid hair contacting the patients mouth.
• If not covered the hair may act as a source of infection,
• Personnel must protect their hair with surgical cap
while encountering heavy splatter e.g. Ultrasonic
scaling device, during tooth preparation procedures.

47. Glove Indication Comment Material
Patient
examination
gloves
Patient care,
examinations, other
nonsurgical procedures
involving contact with
mucous membranes, and
laboratory procedures
Medical device regulated by the Food and
Drug Administration (FDA).
Nonsterile and sterile single-use
disposable.
Use for one patient and discard
appropriately.
Natural-rubber latex (NRL)
Nitrile
Nitrile and chloroprene (neoprene)
blends
Nitrile & NRL blends
Butadiene methyl methacrylate
Polyvinyl chloride (PVC, vinyl)
Polyurethane
Styrene-based copolymer
Surgeon’s
gloves
Surgical procedures Medical device regulated by the FDA.
Sterile and single-use disposable.
Use for one patient and discard
appropriately.
NRL
Nitrile
Chloroprene (neoprene)
NRL and nitrile or chloroprene
blends
Synthetic polyisoprene
Styrene-based copolymer
Polyurethane
Nonmedical
glove
Housekeeping procedures
(e.g., cleaning and
disinfection)
Handling contaminated
sharps or chemicals
Not for use during patient
care
Not a medical device regulated by the
FDA.
Commonly referred to as utility, industrial,
or general purpose gloves.
Should be puncture- or chemical-resistant,
depending on the task.
Latex gloves do not provide adequate
chemical protection.
Sanitize after use.
NRL and nitrile or chloroprene
blends
Chloroprene (neoprene)
Nitrile
Butyl rubber
Fluoroelastomer
Polyethylene and ethylene vinyl
alcohol copolymer

48. MOUTH MASKS
• Masks are worn in the patient treatment
area and when the dentist is manipulating
the prostheses in the laboratory.
• When airborne infection isolation
precautions are necessary (e.g., for TB
patients), a National Institute for
Occupational Safety and Health
(NIOSH)- certified particulate-filter
respirator (e.g., N95, N99, or N100)
should be used.
• Aerosols are airborne debris, smaller than
5ųm in diameter, that remain suspended
in air
• Splatter are larger blood contaminated
droplets which may contain sharp debris.

50. Protective Eye wear

51. Protective Over garments
• Worn to protect the skin and the clothing,
• Should be changed when ever moist or visibly soiled.
Requirements
• light weight -should cover arm,
chest, up to neck and lap when seated.
• Made of cotton/ synthetic fiber.
• Laundry done with regular detergent.
• Hot water up to 70ºc or cool water
containing 50- 150ppm chlorine is
used as anti microbial.

52. D
O
N
N
I
N
G
O
F
PPE

53. D
O
F
F
I
N
G
O
F
PPE

54. D
O
F
F
I
N
G
O
F
PPE

56. SAFE INJECTION PRACTICES

57. Equipment and instrumentation
I. Fumigation systems
II. High volume extra oral suction
III. The indoor air cleaning system
IV. The dental chair water lines should be equipped with
anti retraction valves
V. Used hand pieces with anti-retraction valves only
VI. Chemicals required for disinfection
VII. Appropriate PPE and ensure it is accessible to HCW.
VIII. Maintain a supply of all consumables related to PPE,
Sterilisation and Disinfection

59. Precleaning and cleaning solutions
Enzymatic solutions Removes blood and other proteinaceous material
Non-enzymatic solutions Removes non-specific debris
Mechanical cleaners Washers/disinfectors or ultrasonic cleaners
Rust inhibitors Retards corrosion of carbon steel

60. Process Result Method Examples
Sterilization Destroys all micro-
organisms,
including bacterial
spores
• Heat automated,
high temperature
• Heat automated,
low temperature
• Liquid
immersion
• Steam, dry heat,
unsaturated chemical vapor
• Ethylene oxide gas,
plasma sterilization
• Glutaraldehyde,
glutaraldehydes with
phenols, hydrogen peroxide,
hydrogen peroxide with
peracetic acid, peracetic
acid
High-level
disinfection
Destroys all micro-
organisms, but
not necessarily
high numbers of
bacterial spores.
Heat automated
Liquid immersion
Washer disinfector
Glutaraldehyde,
glutaraldehydes with
phenols, hydrogen peroxide,
hydrogen peroxide with
peracetic
acid, ortho-phthalaldehyde

61. Process Result Method Examples
Intermediate
level
disinfection
Destroys vegetative
bacteria and most
fungi and viruses.
Inactivates
Mycobacterium
bovis. Not
necessarily capable
of killing
bacterial spores.
Liquid contact EPA-registered hospital
disinfectant with label claim
of tuberculocidal activity
Low-level
disinfection
Destroys most
vegetative bacteria
and certain fungi
and viruses. Does
not inactivate
Mycobacterium
bovis.
Liquid contact EPA-registered hospital
disinfectant with no label
claim regarding tuberculocidal
activity. OSHA also requires label
claim of HIV and HBV potency
for use of low-level disinfectant
for use on clinical contact
surfaces (e.g., quaternary
ammonium compounds, some
phenolics, some iodophors)

62. Sterilizers
Steam autoclave Uses steam under pressure to sterilize 250F to 273F(
time varies depending on size of
load and autoclave)
Good penetration of heat into packages causes
Corrosion
Requires drying time
Oven type dry heat Uses dry heat at 320F for 1-2sterilizer hr
No corrosion
Rapid heat transfer
type dry heat Sterilizer
Uses circulated dry heat 375F for 6-20 mins
Unsaturated chemical vapor
sterilizer
Uses unsaturated chemical vapor from formaldehyde
and alcohol 273F for 20 mins

63. Surface Asepsis
• There are two general approaches to surface
asepsis
- Clean and disinfect contaminated surface
- Prevent surface from becoming contaminated
by use of surface covers
- A combination of both may also be used

64. According to Miller and Palenik in 1994 chemicals
used for surface and equipment asepsis are
-Chlorine e.g. sodium hypochlorite
- Phenolic compounds
water based water with ortho- phenyl phenol or tertiary
amylphenol or O benzylp chlorophenol
alcohol based Ethyl or iso propyl alocohol with O phenyl phenol
or tertiary amylphenol
Iodophor butoxypoly propoxy poly ethoxy ethanol iodine
complex

65. Infection-control categories of patient-care
instruments
Category Definition Dental instrument or item
Critical Penetrates soft tissue, contacts bone,
enters into or contacts the bloodstream
or other normally sterile tissue.
Surgical instruments,
periodontal scalers, scalpel
blades, surgical dental
burs
Semicritical Contacts mucous membranes or nonintact
skin; will not penetrate soft tissue, contact
bone, enter into or contact the
bloodstream or other normally sterile
tissue.
Dental mouth mirror,
amalgam condenser,
reusable dental impression
trays, dental handpieces
Noncritical Contacts intact skin. Radiograph head/cone,
blood pressure cuff,
facebow, pulse oximeter

66. •Dapen dishes
• Hand pieces
• Steam autoclave-121°C for 15 to 20 minutes at
15 lb pressure /square inch,
• Ethylene oxide-450-800 mg/l.
• Glass slabs
• Stainless steel Impression trays
•Water- air syringe tips
• Steam autoclave- 121°C for 15 to 20 minutes at
15 lb pressure /square inch,
• Dry heat oven-160°C for 1 hour,
• Chemical vapour-20 minutes at 270° F.
• Ethylene oxide-450-800 mg/l.
• Burs - carbon, steel, diamond
points,
• Hand instruments Carbon steel
• Impression trays, Aluminum metal
tray, Chrome — plated tray, Custom
acrylic resin tray, Plastic tray
• Mirrors (mouth & face)
• Dry heat oven-l60°C for 1 hour
• Chemical vapour-20 minutes at 270° F.
• Ethylene oxide 450-800 mgJl.
Needle Discard; do not reuse
• Polishing wheels and disks
• Saliva evacuators, Ejectors
• X-ray equipment
Ethylene oxide-450-800 mg/I.

67. Dentures • Rinsed under running water, cleaned for debris in an ultrasonic
cleaner and immersed for 12 hours in alkaline glutaraldehyde
disinfection solution.
• Rinsed under running water, 4% chlorhexdine scrub for 15
seconds followed by a 3 minutes contact time with chlorine
dioxide.
• Sterilized by ethylene oxide gas-450-800 mg/I.
Pumice • Addition of antiseptic product containing Octenidine to
conventional pumice,
• Addition of benzoic acid to conventional pumice,
• Working pumice should be discarded after each use
Metal framework • Immersed 3 minutes in 5.25% sodium Hypochlorite solution and
rinsed in water.
• 2% gluteraldehyde solution and held in a plastic bag for 10
minutes

68. Disinfection of impressions
• American Dental Association (ADA) guidelines state that
impressions should be rinsed to remove saliva, blood and
debris and then disinfected before being sent to the
laboratory.
• When considering methods of disinfection for impressions,
two factors are important:
1) the effect of the treatment on the dimensional stability and
surface detail of the impression and
2) the deactivating effect of the impression material on the
disinfecting solution, which could reduce the efficacy of the
process.

69. Impressions
compound,
Zinc oxide eugenol
• Immersed in 2% ID 210 solution for 20 minutes
• Immersed for 10 minutes in 2% glutaraldehyde
Irreversible
hydrocolloid
• Spray with 5.25% sodium hypochlorite, rinse, spray again and
stand under damp gauze or in sealed bag for 10 minutes.
• Immersed in 2% glutaraldehyde for 10 minutes
Reversible
hydrocolloid
Spray with 5.25% sodium hypochlorite, rinse, spray again and
stand under damp gauze for 10 minutes
Polysulphide • Rinsed for 45 seconds with water and immerse for 30 minutes in
2% glutaraldehyde.
• Immersed for 15 minutes in 5.25% sodium hypochlorite solution
and rinsed in water.
Polyether • Immersed in 2% glutaraldehyde for 1 hour at room temperature,
rinsed with sterile water for 45 seconds and dried for 10 minutes
Addition silicone • Immersed in 2% glutaraldehyde for 1 hour, rinse in sterile water
Condensation
silicone
• Immersed in 2% glutaraldehyde for 10 minutes and washed with
sterile water
wax bites/ rims,
bite registrations
• 5.25% sodium hypochlorite solution and placed in a plastic bag
for 10minutes
casts • sprayed with a 5.25% sodium hypochlorite solution and allowed
to sit for at least 10 minutes

70. • Large, non-sterilizable items used in the
operatory, such as impression material
dispensing guns, articulators, face bows, water
bath, silicone spray bottles, tooth shade, and
mold guides are disinfected by wiping,
spraying, or immersion with the appropriate
disinfectant solution.

71. Environment and Surface Disinfection
• Floors: 2 Step Cleaning Procedure (Detergent and freshly
prepared 1% sodium hypochlorite with a contact time of 10
minutes. Mop the floor starting at the far corner of the room
and work towards the door. Frequency: after any patient/
major splash or two hourly.
• Rest of the surfaces : Freshly prepared 1% sodium
hypochlorite (Contact Time: 10 minutes). Damp dusting
should be done in straight lines that overlap one another.
Frequency: before starting daily work, after every procedure
and after finishing daily work.
• Delicate Electronic equipment Should be wiped with
alcohol-based rub/spirit (60-90% alcohol) swab before each
patient contact.

72. Patient Treatment
• The responsibility for infection control
procedures during patient treatment rests
primarily on the dentist’s ability to adhere to
strict sterilization, disinfection and barrier
techniques.
• The use of strict system of zoning in the clinic
will reduce the number of areas contaminated
and there by maintain asepsis.

73. Protocols of patient and clinic area before starting the
treatment
• The working area is sprayed and left for 10 mins before any
procedure starts along with the wiping of the operatory and
chair with a disinfectant solution.
• The chair is covered with a disposable plastic sheath which
has to be removed subsequent to the treatment.
• All the patients are advised to rinse with chlorhexidine
gluconate 0.12% and wear protective eye wear before the
commencement of the treatment

74. • A unit dose concept may be adopted for use in
the clinic as a cross-contamination control
measure.
• This may be applied to many items and
materials in prosthodontics, such as impression
materials and waxes.

75. Protocols of patient handling in the clinic area
• For appointments that do not result in aerosols,
and need examination only wear a triple layer
surgical mask and protective eyewear/face shield
and gloves.
• Wear N95 face masks, protective eyewear/face
shields and gloves along with coverall for High
Risk and very high-risk procedures.
• To increase the shelf life of N95 masks, you may
cover them with a surgical mask and discard only
the surgical mask after use.

76. • When examining patients with moderate risks the
treating doctor will require all PPE as high risk
except that the coveralls can be substituted with
surgical gowns.
• Practice non-aerosol generating procedures.
• Use of rubber dam is encouraged.
• The 4-handed technique is beneficial for
controlling the infection.

77. Patient discharge protocol
I. The patient drape will be removed by the
assistant, and the patient is asked to perform
hand wash and guided out of the clinic towards
reception and handed back his foot wears and
belongings.
II. The procedures and prescription is recorded
only after doffing the PPE.
III. Patient to perform hand hygiene and to be
provided with review /follow up instructions.

78. • Patient turn around and disinfection
protocol
I. After the patient leaves the treatment room, the Assistant will collect all hand
instruments immediately, rinse them in running water to remove organic
matter and as per standard sterilisation protocol.
II. All 3 in 1 syringe, water outlets, hand piece water pipelines, etc. should be
flushed with the disinfectant solution for 30-40 seconds.
III. Remove water containers and wash them thoroughly and disinfect with 1%
sodium hypochlorite using clean cotton/ gauge piece and then fill with
fresh 0.01% sodium hypochlorite solution and attach back to the dental
chair.
IV. Then, disinfect the Dental Chair along with all the auxiliary parts within 3
feet of distance using 1% sodium hypochlorite and clean and sterilised
cotton/gauge piece using inner to outer surface approach and leave for
drying.

79. New cotton/ gauge piece should be used for every
surface. The areas include:
a. Patient sitting area and armrests
b. Dental chair extensions including water outlets,
suction pipe, hand piece connector, 3 in 1 syringe,
etc.
c. Dental light and handle
d. Hand washing area –slab and tap nozzle
e. Clinic walls around the dental chair and
switchboards

80. V. Hand pieces should be cleaned using a hand piece cleaning
solution to remove debris, followed by packing in the
autoclave pouches for autoclaving. Record to be maintained
for the same.
VI. IMPRESSIONS will be thoroughly disinfected before
pouring or sending to the laboratory using an appropriate
disinfectant.
VII. Remove visible pollutants completely before disinfection.
Mop the floor with 1% sodium hypochlorite solution
through separate mops for the clinical area following
unidirectional mopping technique from inner to outer area.
Wash and disinfect the mop with clean water and 1%
sodium hypochlorite and leave it for sun-drying.

81. Phase III Patient follow-up and Review
• The patient should be contacted telephonically
24 hrs and in a week’ time to know if he has
developed any symptoms that should warn the
dental Staff to undertake appropriate actions.
• He should be advised to inform back to the
dental clinic should there be any adverse
symptoms.

82. Laboratory disinfection
• The dental laboratory becomes the second line of infection
control barriers that protect the patients, residents,
assistants, and faculty.
• Those leaving the laboratory are immersed in a 5.25%
sodium hypochlorite solution for a minimum of 10 minutes.
• Laboratory countertops are cleaned and wiped with
disinfectant solution at the end of each day. Individually
packaged chemiclaved laboratory burs are available in the
laboratory.
• After the desired procedure is accomplished, the laboratory
bur is cleaned and placed in a new bag for sterilization. The
burs are used for one patient only and then re sterilized.

84. • For polishing the lathe, when the technician
should use individually packaged sterile
polishing wheels, designated for use with
pumice.
• The addition of an antiseptic product that
contained Octenidine as active agent to
conventional pumice reduced the number of
microorganisms by 99.999%.
• The mix of steribim with water reduced the
number of bacteria by 99%.
• The wheel is wet with water to soften it
before use.
• If prosthesis becomes contaminated during
laboratory procedures, it is disinfected and
the laboratory procedure continued.

85. • Final polish is accomplished using a sterile wheel with
non contaminated acryluster.
• The acryluster is applied to the sterile wheel once
before polishing to eliminate cross-contamination.
• Cleanup involves disposal of the plastic container and
the contaminated pumice.
• Wheels are removed, rinsed under water, and bagged
for autoclaving.

86. Protocol for clinic closure
The commercially available hydrogen peroxide is 11% (w/v) solution which is
stabilized by 0.01% of silver nitrate

87. CLINICAL WASTE DISPOSAL
• Regulated medical waste is only a limited subset of
waste: 9%-15% of total waste in hospitals and 1%- 2%
of total waste in dental offices
• Examples of regulated waste found in dental practice
settings are solid waste soaked or saturated with blood
or saliva (e.g., gauze saturated with blood after
surgery), extracted teeth, surgically removed hard and
soft tissues, and contaminated sharp items (e.g.,
needles, scalpel blades, and wires.
• Adding 5% hypochlorite in water to suctioned fluids is
recommended before disposing into the drain.

90. Conclusion
• The increased awareness of the dangers of cross
contamination with hepatitis B virus (HBV) and HIV
and now corona virus during dental procedures is
having a growing impact on attitudes toward infection
control in the dental clinic and laboratory.
• Lack of Infection Control is life-threatening for both
the patient and the Dental Professional and requires
more efforts.
• So, it is the duty and responsibility for each and every
doctor and a technician to follow the infection control
protocol in order to protect the patients from contagious
disease and microorganisms.

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