Infection Control and Sterilization

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In the 1980s, the ADA Foundation’s Health Screening Program helped identify hepatitis B virus as an occupational hazard in dentistry. The ADA responded by being the first entity to recommend that dentists and dental offices follow standard infection control procedures. The ADA subsequently worked with the Centers for Disease Control and Prevention (CDC) to develop CDC’s own infection control recommendations for dentistry, which were originally issued in 1993.1 Since then, the CDC has updated and supplemented their recommendations to reflect new scientific knowledge and growing understanding of the principles of infection control.2, 3

In addition to the standard infection control procedures discussed on this page, the CDC recommends the following nonpharmaceutical interventions (NPIs) to help limit the spread of influenza,4 urging dental staff and patients to always:

During influenza pandemics, CDC recommends more stringent NPIs:4

While the CDC provides recommendations for infection control in healthcare and dental settings, the Occupational Safety and Health Administration (OSHA) regulates and enforces infection control measures among staff and employers, including within dental offices. The Bloodborne Pathogens standard (CFR 1910.1030) protects workers who may be exposed to infectious materials in their workplace. Please see the Oral Health Topics page on OSHA for more information.

In December 2003, the CDC published a major consolidation and update of its infection control recommendations for dentistry.2 The 2003 document incorporated relevant recommendations that were previously published in several other CDC documents and contained an extensive review of the science related to dental infection control. In March 2016, the CDC issued the new “CDC Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.”3 Although not intended as a replacement for the 2003 Guidelines document, the new CDC Summary is targeted to “anyone who seeks information about basic infection control in dental settings and includes several new recommendations as well as an assessment checklist.” Although the primary content is essentially unchanged, the new Summary document brings together recommendations from the 2003 CDC guidelines as well as other recommendations published in CDC guidance documents since 2003.

The 2003 CDC Guidelines and 2016 Summary are comprehensive and evidence-based sources for infection control practices relevant to the dental office that have been developed for the protection of dental care workers and their patients. The new resource includes tools to help dental health care personnel follow infection prevention guidelines, including:

The updated recommendations3 emphasize the importance of having one person in every dental practice assigned to be the infection prevention coordinator. The coordinator would develop written infection prevention policies based on evidence-based guidance outlined in the new resource. The coordinator can help ensure that dental health care personnel are aware of the equipment and supplies necessary to address infection prevention issues with all staff members.

The ADA has long advocated the use of infection control procedures in dental practice and provided dentists with resources to help them understand and implement them. The ADA urges all practicing dentists, dental auxiliaries and dental laboratories to employ appropriate infection control procedures as described in the 2003 CDC guidelines and 2016 CDC Summary and to keep up to date as scientific information leads to improvements in infection control, risk assessment, and disease management in oral health care.

The CDC distinguishes several levels of sterilization and disinfection of patient-care items according to the level of risk based on intended use. Items must be cleaned prior to disinfection or sterilization.

Manufacturer’s instructions must be followed for the use of EPA-registered disinfectants and FDA-cleared sterilants and high-level disinfectants, and intended use must be clearly stated on the label; if not, do not use the product. Similarly, reusable devices must provide clear instructions for reprocessing and should not be reused. For more detailed information please see the 2003 CDC recommendations, the 2016 CDC update, or the ADA Practical Guide to Effective Infection Prevention and Control.

In April, 2018, the CDC released a Statement on Reprocessing Dental Handpieces stressing that handpieces (both low-speed and high-speed) and other intraoral instruments that can be removed from the air lines and waterlines need to be heat sterilized between patients,5, 6 and that reusable devices made prior to 20156 may not meet current FDA reprocessing guidance.7 The CDC Statement reaffirmed and clarified 2003 CDC recommendations2 and emphasized three key points:6

If a dentist is concerned about the validity of the manufacturer’s reprocessing instructions, or believes that the instructions are not consistent with basic infection prevention and control principles, they can contact the manufacturer to request documentation of FDA clearance of the device in question. If the manufacturer is not able to provide sufficient information, dentists can contact FDA’s Office of Compliance for assistance, at [email protected] or 1-240-402-7675.

Along with the proper sterilization of instruments and materials, sterilizer monitoring is an essential part of any in-office infection control program.

Many factors can cause sterilization to fail—from procedural errors that are easily remedied, like overloading, to mechanical problems that can take a sterilizer out of service until repairs can be made. Since this variety of factors can influence successful sterilization, the ADA and CDC encourage dentists to regularly assess the efficiency of their in-office sterilizers.2, 8, 9 In addition, state or local regulations may exist regarding frequency and record-keeping issues related to sterilizer monitoring. Check with your state dental board for regulatory information.

Sterilization is best monitored using a combination of mechanical, chemical, and biological indicators.8 The CDC has provided the following recommendations:2, 3, 9

Mechanical Indicators

Chemical Indicators

Biological Indicators

provide more accuracy than in-house monitoring.

What to Do When Results Confirm Sterilization Failure

If the biological indicator test is positive, or the mechanical or chemical test results indicate failure, the sterilizer should not be used until the reason for failure has been identified and corrected.

Before the sterilizer can be returned to service, the biological indicator should return negative results for tests conducted during three consecutive empty-chamber sterilization cycles to ensure that the problem has been corrected.

INFECTION CONTROL IN THE PRACTICE OF DENTISTRY(Trans.2012:470; 2019:XXX)

Resolved, that it be ADA policy to support the implementation of standard precautions and infection control recommendations appropriate to the clinical setting, per the 2003 Guidelines for Infection Control in Dental Health Care Settings and the 2016 Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care from the Centers for Disease Control and Prevention (CDC), and be if further

Resolved, that the ADA urges practicing dentists, dental auxiliaries and dental laboratories to keep up to date as scientific information leads to improvements in infection control,

and be it further

Resolved, that this policy includes implementation of CDC recommendations for vaccination and the prevention and management of exposures involving nonintact skin, mucous membranes and percutaneous injuries.

American Dental AssociationAdopted 2012; Amended 2019

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The CDC website has a section on infection control that is designed for dental professionals. Following are relevant links to additional information from the CDC and other agencies and organizations.

Topic Updated: October 5, 2022

Prepared by:

Department of Scientific Information, Evidence Synthesis & Translation Research, ADA Science & Research Institute, LLC.

Disclaimer

Content on this Oral Health Topic page is for informational purposes only. Content is neither intended to nor does it establish a standard of care or the official policy or position of the ADA; and is not a substitute for professional judgment, advice, diagnosis, or treatment. ADA is not responsible for information on external websites linked to this resource.