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Infection Control

Infection control practices in dental radiology

Joseph A. Bartoloni, DMD

David G. Charlton, DDS, MSD

Diane J. Flint, DDS

The potential for cross-contamination in dental radiology is extremely high, especially when intraoral radiographs are exposed and processed. This report describes specific infection control practices that are recommended to decrease the potential for crosscontamination in dental radiology and reduce the likelihood of disease transmission. Received: February 21, 2002 Accepted: April 30, 2002

Since the beginning of the AIDS epidemic, an increased emphasis has been placed on medical and dental work practices to minimize bloodborne pathogen exposure. In 1990, public concern regarding dental infection control grew after the CDC reported a possible clinic-acquired HIV transmission within the dental setting.1 In 1991, OSHA established the Bloodborne Pathogens Standard to protect employees from exposure to potential pathogens in human body fluids.2 This document mandated that personal protective measures be implemented in health care settings to safeguard employees who could come in contact with potentially infectious materials, including blood or saliva. Dental patients and dental health care workers (DHCWs) are exposed to a number of infectious disease agents during the delivery of treatment. To minimize the risk of cross-contamination (that is, the passage of microorganisms from one person or inanimate object to another) that may transmit disease, both the CDC and the ADA have published dental infection control guidelines, which are revised periodically to include the most updated information.3,4 Because blood and saliva can harbor life-threatening microbes, health care workers providing dental care may be exposed to a variety of pathogens (see Table 1). Studies have shown that operatory equipment, surfaces, and materials used during treatment can become heavily contaminated through cross-contamination from saliva and blood-coated hands as well as gloved hands, which can serve as a source for the indirect spread of microorganisms.5-8 Infection control practices are designed to create and maintain a safe clinical environment to eliminate or minimize disease transmission during patient treatment.

In an effort to reduce transmission of bloodborne pathogens between DHCWs and patients, in 1988 the CDC emphasized the use of Universal Precautions, meaning that all patients should be considered potentially infectious and that the same infection control procedures should be used for every dental procedure where a DHCW could come into contact with blood or saliva.9 In 1996, the CDC developed guidelines combining Universal Precautions and body substance isolation. These guidelines are known as Standard Precautions, which consider all body fluids, secretions, and excretions (except sweat) as potentially infectious, regardless of whether they contain blood.10 Initially developed for use in the care of patients in hospitals, Standard Precautions gradually have replaced Universal Precautions in all types of health care settings. To prevent or reduce the risk of workrelated infections for DHCWs and their patients, all dental facilities should have a well-written, frequently updated infection control plan. The plan should include policies and standard operating procedures for patient care, including dental radiology. Infection control practices for dental radiography, like those utilized in the dental operatory, are based on Standard Precautions. The potential for cross-contamination in dental radiology is extremely high, because taking and processing intraoral radiographs involves a multi-step process including both intraoral and extraoral procedures. Several studies have confirmed that cross-contamination occurs during the exposure and processing of intraoral films. Rahmatulla et al found that most high-touch areas in dental radiology, including the dental chair headrest adjust-

ing lock, the x-ray cone, the exposure control knob, the timer switch, the x-ray film placement area in the darkroom, the x-ray film feeding area in the automatic film processor, and the revolving door to the darkroom, became contaminated while taking radiographs.11 White and Glaze found that the DHCW can transfer oral microorganisms from the patients oral cavity to radiographic equipment during routine intraoral radiography.12 These microorganisms remain viable on radiographic equipment for at least 48 hours. Bachman et al demonstrated that contaminated films cross-contaminate radiographic processor equipment, because the developing process does not destroy the microorganisms.13 Bacteria can survive in used dental radiographic developer and fixer for up to two weeks.14 A 1993 report by Stanczyk et al discovered that microorganisms on contaminated radiographic film can survive the processing cycle, meaning subsequent films frequently become crosscontaminated within the processor.15 In addition, the processor and daylight loader could become contaminated and remain so even after 48 hours of inactivity.15 A number of articles offer suggestions and specific information regarding proper infection control procedures for exposing and processing dental radiographs.16-36 As mentioned earlier, infection control practices in dental radiology are similar to those used in the dental operatory, including the wearing of appropriate personal protective equipment; handwashing; using surface barriers; cleaning and disinfecting equipment and environmental surfaces; and cleaning, disinfecting, and sterilizing instruments. Each of these procedures will be discussed in detail.

Personal protective equipment

All DHCWs should wear gloves to prevent skin contact with blood, saliva, mucous membranes, and contaminated items or surfaces. Gloves also should be worn when taking intraoral radiographs and when handling contaminated film packets, equipment, supplies, and instruments. Powder-free gloves are recommended

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Table 1. Microorganisms that may be present in blood or saliva.

Bacteria

Mycobacterium tuberculosis Streptococcus pyogenes Streptococcus pneumoniae Staphylococcus aureus Staphylococcus epidermis Haemophilus influenza Treponema pallidum Neisseria gonorrhoeae

Viruses HIV Hepatitis B Hepatitis C Herpes simplex 1 and 2 Cytomegalovirus Epstein-Barr Measles rubeola/rubella Cold/flu Varicella-zoster

Fig. 1. To minimize cross-contamination, only those items necessary for the procedure should be dispensed. This process is known as unit dosing.

because powder can affect the films emulsion layer and cause image artifacts. Gloved DHCWs should either avoid touching nonbarrier-protected surfaces or use an overglove, such as an oversized food handlers plastic glove. Gloves are single-use items and should be changed between patients; they should never be washed or disinfected for reuse and should be removed and changed if they become torn, cut, or punctured during treatment. It usually is not necessary to wear impervious gowns, long sleeves, masks, or protective eyewear during routine dental radiology procedures as long as no aerosols, droplets, or spatter are generated, although these should be considered when treating patients with gagging problems or respiratory infections, such as the common cold.

tients, which has the additional benefit of reducing turnaround time. If uncovered surfaces are contaminated, they should be disinfected after the patient leaves. Contaminated surface barriers should be changed between patients and gloves should be worn when removing and discarding surface barriers.

Cleaning and disinfection of equipment and environmental surfaces

Following a patients treatment, all surfaces and items contaminated with blood or saliva should be thoroughly cleaned and disinfected using a suitable chemical germicide that provides intermediatelevel disinfection. By definition, intermediate-level disinfectants destroy Mycobacterium tuberculosis, hydrophilic and lipophilic viruses, fungi, and vegetative bacteria but not bacterial spores. Chemical germicides appropriate for use in dental facilities should be labeled hospital-grade and have an EPA number. Hospital-grade germicides demonstrate efficacy against Staphylococcus aureus, Pseudomonas aeruginosa, and Salmonella choleraesuis. They also should be tuberculocidal, capable of killing M. tuberculosis. The manufacturers instructions should be followed carefully with regard to dilution, use, and material compatibility. Heavy-duty utility gloves should be worn when using chemical germicides.

Handwashing
Proper handwashing is one of the most important means of preventing disease transmission. All DHCWs should wash their hands thoroughly before and after patient treatment (that is, before gloving and after removing gloves). Ungloved hands should be washed after touching any contaminated item or surface. Gloves are not a substitute for handwashing.

Surface barriers
Any surfaces and objects that may be touched by contaminated gloved hands during treatment should be covered with some type of disposable, impervious barrier such as household plastic wrap, a plastic bag, plastic sheets or tubing, or aluminum foil. Surface barriers provide adequate protection against cross-contamination while eliminating the need to clean and disinfect surfaces between pa-

Cleaning, disinfection, and sterilization of instruments and items

Most reusable instruments and items used in dental radiology are considered semicritical (contacting the mucous membrane) or noncritical (contacting in-

tact skin). Reusable semicritical items such as x-ray film holding and positioning devices should be barrier-protected or treated with a high-level disinfectant at the very least. High-level disinfectants are capable of destroying or inactivating all microbial life (including bacterial spores) as long as they are used in sufficient concentrations and with appropriate contact times; however, reusable semicritical items should be sterilized between patient use. If routine sterilization of semicritical items is not possible, disposable items should be substituted. Noncritical items (for example, the x-ray cone, exposure button, and lead apron) require only intermediate-level disinfection. The exposure and processing of intraoral radiographs are not routinely associated with blood and saliva splatter but disease transmission still is possible through direct contact or cross-contamination. Therefore, specific infection control practices for dental radiology are recommended that should be followed before, during, and after film exposure as well as during the processing of intraoral radiographs. Prior to film exposure, the x-ray exposure area should be prepared using an aseptic technique, one which breaks the chain of infection and prevents cross-contamination. All necessary supplies, equipment, and instruments should be prepared before the patient is seated; only the amount necessary for each procedure should be dispensed. This concept, known as unit dosing, is essential for minimizing cross-contamination (Fig. 1). Unit dosing reduces both chairside time and the DHCWs contact with environmental surfaces. The DHCW should barrier-protect all surfaces that are likely to be touched

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Table 2. Surfaces that

should be protected prior to radiographic procedures. Tubehead/yoke X-ray cone Control panel Exposure button Headrest Headrest adjustment control Chair adjustment control Work area or countertop

Fig. 2. Surface barriers covering the tubehead/yoke, x-ray cone, and headrest.

Fig. 3. A surface barrier covering the tubehead and x-ray cone.

Fig. 4. A surface barrier covering the control panel of an x-ray machine.

Fig. 5. A foot switch, used to activate the exposure while maintaining infection control.

Fig. 6. A surface barrier completely enclosing the remote switch.

Fig. 7. Aseptic dispensing of dental radiographic film prior to the procedure.

Table 3. Infection control practices before film exposure.

Before the patient is seated The DHCW should unit dose the following items: preprocedural mouthrinse; paper towels; surface disinfectant; surface barriers; powder-free gloves; radiographic film(s); sterile or disposable film holders; paper cups or plastic bags; overgloves; lead apron with thyroid collar; and cotton rolls. The patient should rinse with a preprocedural mouthrinse to reduce the number of oral microorganisms and minimize the potential for cross-contamination via direct contact.

After the patient is seated Adjust the headrest and chair position. Place the lead apron with thyroid collar. Have the patient remove any items that may interfere with film exposure (eyeglasses, dentures, and so forth). After completing these procedures, the DHCW should wash his or her hands thoroughly and don gloves. If using reusable film-holding devices, they should be removed from the sterilized package and assembled. All of these steps should be performed in the patients presence.

Fig. 8. Film barriers. Left: film placed in a barrier. Right: prepackaged film with a ClinAsept barrier.

during the radiographic procedure (see Table 2). Figures 24 show the proper use of barriers on radiographic equipment. As with other operatory equipment, using a foot switch or a wrapped, hand-held remote switch with the x-ray unit can reduce contact and minimize cross-contamination (Fig. 5 and 6). Dental radiographic film should be dispensed aseptically from a central supply area and placed in a disposable container, such as a paper cup or plastic bag

(Fig. 7). Other items that should be dispensed aseptically from a central supply area include reusable film-holding devices (which also should be packaged and sterilized between patient use); cotton rolls (to stabilize film placement); and paper towels, which can remove excess saliva from exposed films and protect work surfaces where film could be placed after exposure. Tables 35 list proper infection control practices before, during, and after exposure and during processing. Table 6

lists infection control practices during film processing.

Handling films with and without barriers

Film barriers offer a simple method for maintaining proper infection control measures when using a daylight loader. Tests have shown that film barriers, when placed correctly, prevent the penetration of fluids.34 Commercially available film barriers such as ClinAsept (Eastman

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Table 4. Infection control practices during film exposure.

Fig. 9. Barrier-protected film, opened carefully and allowed to drop onto a paper towel to prevent contamination.

The DHCW should touch as few surfaces as possible; those surfaces should be barrierprotected. Dry each film with a paper towel after taking it from the patients mouth to remove excess saliva. Place the film in a disposable container such as a paper cup or plastic bag before transporting it to the processing area (Fig. 13). Do not touch the disposable container while wearing contaminated gloves. During exposures, film-holding devices should be transferred to a covered work surface protected by a surface barrier. If the DHCW must leave the work area during film exposure, gloves must be removed and hands washed. Before resuming with film exposures, the hands should be washed again and new gloves donned.

Table 5. Infection control practices after film exposure.

Fig. 10. Technique for aseptically removing a dental radiographic film from its barrier and allowing it to fall into a paper cup.

After use, reusable film-holding devices should be placed in an area designated for contaminated instruments. All disposable contaminated items (for example, cotton rolls, bitewing tabs, paper towels, and surface barriers) should be discarded in accordance with local and state environmental regulations; gloves should be worn when handling them. The DHCW should unwrap all covered surfaces carefully while ensuring that the underlying surface remains untouched with the contaminated gloves. The gloves should be removed and hands washed once all contaminated items are removed and disposed. At that point, the lead apron may be removed and the patient dismissed from the x-ray exposure area. Any uncovered areas that were contaminated during the procedure should be cleaned and disinfected using an EPA-registered, hospital-grade, tuberculocidal disinfectant. Because these disinfectants can be skin irritants, DHCWs should wear utility gloves when using them. Remember that chemical germicides may affect the control panels electrical connections, so avoid applying them too liberally.

Table 6. Infection control practices for film processing.

Fig. 11. Using a surface barrier to cover the bite guide and chin rest of a panoramic machine.

Exposed films should be transported to the processing area in a disposable container such as a paper cup or plastic bag. The container should never be touched with contaminated, gloved hands. Prior to taking the films to the processing area, the gloves should be removed, the hands washed, the area cleaned up, and the patient dismissed. The following items should be unit dosed in the processing area prior to starting the processing procedure: gloves; paper towels; paper cups; and film mount or paper envelope. The gloves, paper towels, and paper cups are necessary for film handling prior to processing. A paper envelope or film mount is used to hold and store the film(s) after processing and should be labeled with the patients name and date.

Fig. 12. Digital sensor covered with a plastic sheath and a latex finger cot.

Kodak, Rochester, NY; 800/933-8031), which may be purchased with the film inserted into the barrier, can protect the film packets from contamination while also reducing both preparation and pro-

cessing time. Alternatively, dental facilities can purchase film barriers separately and insert the film into the barrier prior to the radiographic procedure (Fig. 8). Other options include using a finger cot

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Table 7. Procedure for handling films with film barriers.

Place a paper towel on the work surface. Next to the paper towel, place the disposable container containing the films. Don gloves. Remove one contaminated film from the container. Open the film barrier, carefully avoiding contact with the film packet. Allow the film packet to drop onto the paper towel. Dispose of the film barrier. After all film barriers have been opened, dispose of the container. Remove gloves and wash hands. Secure the door and turn out the darkroom lights (if applicable). Unwrap and process the films, handling them by the film edges only. Label a film mount or paper envelope with the patients name and date, using it to hold the processed films.

as a barrier or heat-sealing plastic wrap around the film. Film barriers should be opened carefully in a lighted area using gloved hands. The film packet should be dropped onto a paper towel or into a paper cup for transport to the processing area (Fig. 9 and 10); once the film packet is in the processing area, it may be opened in the conventional manner using ungloved, clean hands. Tables 7 and 8 list the recommended steps when handling films with or without film barriers.

Daylight loaders
Daylight loaders usually have cloth or rubber sleeves, cuffs, or flaps to allow access to the chamber while minimizing light exposure. These units present an additional challenge when processing contaminated film packets because of the potential for cross-contamination in the access openings of the chamber. Table 9 lists steps recommended for processing nonbarrierprotected films in an automatic film processor with a daylight loader.

Table 8. Recommended steps for handling

films not protected by film barriers. Place a paper towel on the work surface. Place the disposable container containing the films next to the paper towel. Secure the door and turn out the darkroom lights (if applicable). Don gloves. Remove one contaminated film from the container. Open the film packet tab, slide out the lead foil backing and black paper, and discard the film packet wrapping. Rotate the lead foil away from the black paper and discard as per local/state regulations. Open the black paper wrapping without touching the film and allow the film to drop onto the paper towel (Fig. 14). Discard the black paper wrapping. Discard the container after all film packets have been opened. Remove gloves and wash hands. Process films, handling them by their film edges. Label a film mount or paper envelope with the patients name and date and use it to hold the processed films. Any area touched by contaminated, gloved hands should be cleaned and disinfected.

Panoramic/cephalometric imaging
Because contamination from blood or saliva is highly unlikely during extraoral radiographic procedures, the infection control practices that should be followed are rather simple (see Table 10). The main infection control concern when taking a panoramic radiograph is the bite guide. This item can be handled in several ways, including barrier-protecting it with a surface barrier (Fig. 11) or finger cot, using a disposable bite guide, or sterilizing a reusable bite guide between each patient use.

Digital imaging
Digital radiography is becoming more common in dentistry, as it is considered to offer advantages such as reduced patient radiation exposure, faster imaging display, elimination of film and darkroom armamentarium, the ability to transmit images electronically, ease of image storage, and the ability to manipulate the images.37 For digital radiography, the equipment located in the operatory includes a receptor, central processing unit (CPU), keyboard, monitor, mobile cart, and possibly a printer. These items can become contaminated with aerosols and spatter generated from dental procedures

Fig. 13. Exposed film is placed in a paper cup for transport.

Fig. 14. Technique for removing a dental radiographic film aseptically from its black wrapper and allowing it to drop onto a paper towel.

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and should be protected. The CPU should be barrier-protected except for the air vent, to prevent overheating. A foot switch can minimize contact with the CPU switches. A commercial vinyl keyboard cover should be used to protect the keyboard. The keyboard cover then should be barrier-protected with plastic wrap, which is changed between patients. The monitor may be wrapped in high-touch areas only; avoid covering the air vents that cool the tube. A screen shade will prevent aerosols from contaminating the monitor screen; if the screen is visibly soiled, it should be cleaned and disinfected with an intermediate-level disinfectant. If a printer is used in the operatory, it also should be barrier-protected with plastic wrap. Again, avoid covering the air vents that prevent heat buildup. There are two basic types of receptors: direct sensors, which are attached to the computer monitor via a cable, and storage phosphor plates, which resemble intraoral film but are reusable and processed in a scanner. Both types of receptors can become contaminated during image exposure and handling. Unfortunately, neither receptor can be autoclaved, so it is important to use effective barrier techniques. Digital system manufacturers recommend plastic sheaths for preventing cross-contamination. Two recent studies have shown reduced rates of direct sensor cross-contamination by augmenting the plastic sheath provided by the manufacturer with a latex finger cot (Fig. 12).38,39 Storage phosphor plates require a barrier provided by the manufacturer and should be handled as described previously for intraoral films. There are no standardized infection control practices for digital radiography at present, but new technologies are being developed to facilitate infection control, including rubber keyboards, keyless keyboards, and flatpanel touchscreens.

Table 9. Steps for processing nonbarrier-protected films

in an automatic film processor having a daylight loader. Place a paper towel on the surface inside the daylight loader compartment. Place a paper cup and powder-free gloves in the daylight loader compartment. Place the container with contaminated films next to the paper cup (Fig. 15). Close the daylight loader lid and place hands through the sleeves. Don gloves. Remove one contaminated film from the container. Open the film packet as described in Table 8. Allow the film to drop onto the paper towel or processor film feed slot. Dispose of the film packet contents in the empty paper cup. After all film packets have been opened, remove gloves and place them in the paper cup. Feed all unwrapped films into the processor, handling them only by their edges (Fig. 16). Remove hands from daylight loader. Wash hands. Lift the lid of the daylight loader to remove all contents. Label a film mount or paper envelope with the patients name and date, using it to hold the processed films.

Table 10. Infection control practices during extraoral radiographic procedures.

Prior to taking an extraoral radiograph, the DHCW should wash his or her hands. The patient should rinse with a preprocedural mouthwash before the procedure. If barriers are used, they should be placed before positioning the patient. After the procedure, ask the patient to remove the barrier on the bite guide (or the disposable bite guide) and place it in the regular waste bin. If this procedure is performed by the DHCW, he or she should don gloves before removing the contaminated item. The gloves should be discarded and hands washed prior to handling the film cassette. For hygienic purposes, the patient chin rest, head-positioning guides, and handgrips can be barrier-protected or cleaned after film exposure. Since patient secretions normally do not contaminate extraoral cassettes, cassettes can be handled with ungloved hands. No other infection control steps are necessary for processing.

Summary
Infection control has become a significant part of dentistry. Dental employers should ensure that their employees comply with the current mandates of Standard/Universal Precautions. In addition, all dental offices and clinics should develop a written infection control plan that describes specific practices to prevent the

Fig. 15. Unit dosing of a paper towel, powder-free gloves, and an empty paper cup. The paper cup with the contaminated films also is placed inside the daylight loader compartment.

Fig. 16. Proper method for handling films as they are fed into the automatic processor.

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transmission of infectious diseases through direct contact and cross-contamination. The key to preventing crosscontamination in dental radiology is to practice proper asepsis to break the chain of transmission of patient contaminants (that is, blood and/or saliva) from the oral cavity to surfaces and items used and/or touched during the radiographic procedure. Specific infection control practices are recommended before, during, and after film exposure and during the processing of intraoral radiographs to prevent cross-contamination. Infection control practices are changing constantly and it is important that dental staff members stay abreast of these changes. The infection control practices outlined here describe a simple, efficient asepsis protocol for the entire dental staff to follow during dental radiographic procedures to prevent cross-contamination. There is no direct evidence suggesting that the spread of oral microorganisms during a radiographic procedure is a major cause of disease transmission between DHCWs and patients but the possibility cannot be ignored. The potential for cross-contamination in dental radiology is very high but using effective infection control practices can reduce this potential significantly, protecting both patients and staff.

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Disclaimer
The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Defense or other departments of the United States Government.

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Author Information
Col Bartoloni is Director, Professional Services at the USAF Dental Investigation Service, Naval Training Center, Great Lakes, Illinois, where Col Charlton is Director, Materials Evaluation. Dr. Flint is a Postdoctoral Fellow in Oral and Maxillofacial Radiology at the University of Texas Health Science Center, San Antonio.

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