Infection Control Across Clinical and Laboratory Dental Settings

All types of dental settings carry a high risk for the transmission of infectious diseases. Dental health care practitioners (DHCPs) come into direct or indirect contact with bodily fluids and, without maintaining proper infection control protocols, may put themselves, their patients, and others at high risk for disease transmission. The focus of this article is on outlining infection control and disease transmission prevention practices between dental patients, general dental practices, and dental laboratories, including the impact of emerging technologies on reducing disease transmission rates.

Commonly Transmitted Diseases and the Chain of Infection Pathways in Dental Settings

A wide range of bacterial and viral infections can potentially be transmitted in dental settings, including herpes virus (types 1 and 2), Hepatitis B and C viruses, SARS-CoV-2, measles, mumps, rubella, influenza, human immunodeficiency virus (HIV), Mycobacterium tuberculosis and others.¹ Those microorganisms can be found in blood or saliva and may survive outside the host for varying periods of time, depending on different factors.²

The modes of transmission vary by type of organism, with some infectious agents being transmitted by multiple routes.³ Rates of disease transmission in traditional dental care settings can be significantly reduced by following established infection control guidelines and standard precautions.⁴ However, the same level of infection control protection must be maintained whenever dental laboratories are involved.² The chances of contamination increase with the amount of time microorganisms are left undisturbed. Not all infectious diseases that could be spread in a dental setting are equally as pathogenic for dental lab technicians, due to factors such as survival of infectious agents outside of the host, disinfection and sterilization procedures, and use of personal protective equipment (PPE). The following microorganisms are most often detected on items sent to the dental laboratory: Staphylococcus species, α-hemolytic streptococci, Micrococci, Diphtheria, Pseudomonas, Bacilli, Enterobacter, Neisseria, and Corynebacterium species.⁵

To effectively prevent the spread of infection and minimize cross-contamination, it is essential to understand the chain of infection in a dental setting. Figure 1 illustrates how infectious diseases can be transmitted between patients, providers, and dental laboratory technicians.

To minimize the transmission of infectious pathogens for both dental personnel and patients, in 1996 the Centers for Disease Control (CDC) introduced Standard Precautions. Standard Precautions are the minimum infection prevention practices, or series of steps applicable to all patients, regardless of their suspected or confirmed infection status.⁶ All items that came into direct contact with the patient should be treated as potentially contaminated, and the dental personnel must follow strict infection control protocols.^6,7 There are several distinct pathways for cross-contamination, which should be monitored to reduce the risks of infections as described below in Table 1.^7,8

Cross-contamination Between the Patient and the Lab

Infection control in the laboratory is essential in preventing the transmission of infectious diseases and includes a set of procedures intended to reduce the proliferation of pathogenic microorganisms by interrupting the chain of infection at critical points during the manufacturing, repair, or delivery of dental prostheses and appliances.⁸ In most cases, dental technicians are exposed to infections due to cross-contamination, where bacteria and other harmful pathogens are unintentionally transferred from one person, object, or surface to another and can take place during critical points of laboratory procedures, such as:^1,8

• During the receiving and handling of contaminated impressions, models, prostheses, and appliances coming from patients’ mouths.

• Not following the cleaning and disinfecting protocols, using improper disinfectants and sterilization methods, not only for the items that were in the patients’ mouths, but also, the work surfaces and laboratory equipment, and in between laboratory procedures.

• Lack of communication between the dental practice and the laboratory regarding disinfection procedures of the items sent.

To better understand the cross-contamination pathways, it is important to mention that not all dental items, based on their utilization, present the same risks of transmitting infectious pathogens, and they can be classified as follows:^7-9

• Critical items are dental instruments and devices that penetrate sterile body tissues and/or fluids and represent the highest risk of infection if contaminated; therefore, they must be sterile before use.

• Semi-critical items are dental instruments and devices that come in contact with mucous membranes without penetrating the tissue or vascular system, and they can be contaminated by body fluids and blood. These items must have a high to medium level of sterilization or disinfection before use, or it is recommended to use disposable, single-use items in this category.

• Non-critical items are dental instruments and devices that have no contact with sterile body tissue and/or fluids; however, this does not mean they are unimportant. These items have the lowest risk of disease transmission and should have a medium or low disinfection level.

Following this classification is crucial in determining the appropriate methods of sterilization, sanitation and disinfection, recommended types of PPE, methods of managing waste, and hand hygiene procedures.^7-9

Types of Infection Control Procedures in a Dental Setting

For an infection to occur, sufficient quantities of infectious pathogens, which might be transferred via multiple routes of entry into a susceptible host, must be present. This process is called the chain of infectious disease transmission and describes how infectious pathogens are transmitted from person to person or from place to place.^7,10 Different methods and practices, such as surveillance, isolation, outbreak management, hand hygiene, use of personal protective equipment (PPE), and decontamination, are recommended to control the chain of infectious disease transmission.¹¹

Surveillance, which involves monitoring for healthcare-associated infections (HAIs) and reporting them appropriately, helps identify outbreaks and assess the effectiveness of ICPs.^12,13 The goals of surveillance are to protect the patients and the health care workers, visitors, and others in the health care environment in a timely, efficient, and cost-effective manner.¹³

Isolation refers to confining the infected patient or area with the intent of breaking the chain of infection. Isolation is a preventive measure to mitigate the risks of spreading infectious pathogens and making it easier to contain the infection. Common preventive measures in dental settings include rescheduling patients who show signs of infection and ensuring that dental personnel with infectious illnesses take time off from work.^3,11

Outbreak in the dental setting refers to an increased number of incidents of a particular infection affecting patients or dental personnel, and based on the characteristics of the outbreak, it can be either a common-source or a propagated outbreak. There are several steps in managing an outbreak:^11,14

• Verifying outbreak.

• Defining the outbreak.

• Identifying the source.

• Implementing control measures.

• Informing patients, personnel, and other authorities.¹⁴

Personal Protection Equipment (PPE) is used to shield the mucous membranes, respiratory tract, skin, and clothing from direct contact with infectious pathogens.³ Appropriate PPE for different types of patient interactions must be available. It should effectively cover personal clothing and skin, likely to be soiled with blood, saliva, or other potentially infectious materials.¹¹

DHCPs should be trained to properly select, place, and remove PPE to reduce the chance of skin or clothing contamination. Prevention of further spread of contamination while wearing PPE must be continuously emphasized. Hand hygiene is always the final step after removing and disposing of PPE.¹¹

Regarding hand hygiene, wearing gloves alone does not protect against cross-contamination.¹⁵ Performing hand hygiene procedures according to the guidelines provided by the CDC is an essential step in interrupting the disease transmission process. Hand hygiene is a general term that refers to hand washing, hand sanitizing, the use of antiseptic hand rub, and surgical scrub.^7,15 In both clinical and laboratory settings, it is recommended that hand hygiene be performed before and after treating each patient, before placing and after removing gloves, after touching inanimate objects that may be contaminated, before leaving the treatment room, and anytime when hands appear visibly soiled.^7,15,16

Appropriate agents, such as antimicrobial soap, non-antimicrobial soap, or antiseptic hand rub, must be applied using sufficient quantities as recommended by the manufacturer, and handwashing techniques must be executed for the recommended period of time to ensure compliance with established guidelines and effectively reduce cross-contamination.¹⁵ Additionally, care must be taken to minimize skin irritation and contact dermatitis associated with frequent hand washing. Use of hand care products such as creams and lotions needs to be tested for compatibility with gloves, to avoid increased permeability, and for negative effects on the antimicrobial capacity of hand hygiene products.^7,15

Decontamination. It is critical to understand the difference between sterilization, sanitation, and disinfection, because each procedure is intended for different critical points in clinical or laboratory procedures, and correlates to the classification of dental items (critical, semi-critical, non-critical).

Critical Points in Infection Control Protocols and Best Practices to Minimize Cross-Contamination

In the clinical setting, patients are to use preprocedural mouthrinse to reduce bacterial load and minimize contamination during aerosol-producing procedures. Patients are required to wear protective eyewear to prevent potential injuries and eye infections.⁷ Proper barrier protection, use of PPE, disinfection, and sterilization techniques must be followed for all procedures performed in a clinical setting.^2,7 Items that cannot be sterilized, such as impression material dispensing guns, articulators, face bows, silicone spray bottles, shade guides, and molds, should be disinfected with the appropriate disinfectant solution.² All items that came into direct contact with the patient or were touched during treatment must be disinfected before leaving the clinical setting and being transported to the laboratory.² Effective communication and coordination between the dental laboratory and dental practice help ensure that proper cleaning and disinfection procedures are carried out in the appropriate setting. This prevents damage or distortion of materials from overexposure to disinfectants and avoids unnecessary duplication of disinfection efforts.¹¹

Establishing a laboratory barrier system is essential, and this includes setting up a designated receiving area that is physically separated from the rest of the dental laboratory. In this area, all items received from the dental office should be properly disinfected, sterilized, and cleaned before moving on to the next stage of prosthesis or appliance fabrication. To ensure the use of appropriate decontamination methods, dental personnel must understand the differences between disinfection, sterilization, and cleaning procedures. Additionally, it is recommended that the effectiveness of all decontamination processes be regularly monitored and verified using biological indicators to confirm whether infectious pathogens have been eliminated or rendered inactive.¹¹

To ensure the efficiency of decontamination, first, the cleaning process or sanitation is recommended to remove most or all debris, such as blood, saliva, and other body fluids, which may contain infectious pathogens, from surfaces and/or instruments. This can be done using automated cleaning equipment such as ultrasonic cleaners or washer disinfectors and must be done before sterilization or disinfection.¹⁹

The next level of decontamination, intended to destroy all forms of life within an environment, including all infectious pathogens and viruses, is sterilization, which is a complex procedure requiring specialized, FDA-approved equipment, adequate space, and trained dental personnel. The efficiency of this process is determined by utilizing the correct temperatures, duration, and other operational parameters specified by the equipment’s manufacturer, as well as the proper use of containers, wraps, etc. Instruments and other dental items can be sterilized using different methods based on the contamination levels (critical, semi-critical, and non-critical).

Heat-tolerant dental instruments can be sterilized either using autoclaving, dry heat, or unsaturated chemical vapor.^7,11 Other sterilization methods are used for heat-sensitive critical and semi-critical items such as immersing the instruments in a sterilant solution, which is a liquid chemical germicide and low-temperature sterilization with ethylene oxide gas, ETO.¹¹ It is important to mention that heat sterilization procedures can be monitored and verified with frequent spore testing and the use of sterilization indicator strips.⁸ However, sterilization by high-level disinfectant solutions cannot easily be monitored or verified.^8,9,11

Disinfection is defined as the destruction or suppression of most infectious pathogens during their active stage when they can rapidly spread.⁹ Because this decontamination method involves the inactivation of the viruses, unlike sterilization, it does not kill the infectious pathogens and is more difficult to monitor and verify its efficiency. The chemical disinfectants used in dental care settings must be tuberculocidal, because tuberculosis is an airborne disease that spreads easily if not contained.^7,9 According to the Environmental Protection Agency (EPA), disinfectants are classified by their level of disinfection, which depends on their antimicrobial activity against infectious pathogens and the required contact time with surfaces or items:²⁰

• High-level disinfectants or sterilizing solutions/agents are antimicrobial disinfectants against all types of infectious pathogens and are used for critical and semi-critical items.⁹

• Intermediate-level disinfectants are not efficient in killing spores, but they work very well against all other types of infectious pathogens, and they are used for semi-critical and non-critical items.

• Low-level disinfectants are ineffective against some viruses, spores, especially M. tuberculosis, which can cause tuberculosis.^8,9

General safety recommendations for handling disinfectants include using them in well-ventilated areas, wearing appropriate personal protective equipment (PPE), ensuring containers are tightly closed and properly labeled, and having emergency procedures in place for spills or accidental exposure.^9,21

Waste management refers to sorting and categorizing waste, its containment, and its disposal, including biohazardous materials, sharps, and pharmaceutical and chemical waste. There are two categories of waste: non-regulated, which includes items that are not contaminated or infected (such as paper, packaging, food waste, etc.), and regulated waste, which includes sharps, biohazardous, pathological, hazardous, and chemical waste. For regulated waste, it is recommended to use designated, labeled containers that can be sealed and are puncture-resistant; maintain accurate records of waste and its disposal; and follow federal, state, and local regulations and guidelines.²⁷

Another measure to safeguard the dental personnel and patients from exposure to harmful chemicals and products used in infection control is to maintain documentation and records of all the dental materials and all chemicals used. As part of the OSHA Hazard Communication Standard, the dental practices and laboratories must use Safety Data Sheet, SDS, which is a document issued by the manufacturers describing the properties of a product, such as chemical composition, flammability, reactivity, toxicity and environmental impact; the instructions for safe handling, storage, disposal and information about the potential hazards and how to mitigate these risks for protecting the health of the dental personnel and patients. These documents should be easily accessible to all personnel and kept up to date.^28,29

The Effects of Sterilization and Disinfection on Dental Materials, Instruments, and Equipment

While effective sterilization and disinfection are essential for preventing cross-contamination, it is equally important to follow the manufacturer’s instructions. Certain chemicals can alter the properties of dental materials, including prostheses and appliances, and may impact the proper use of instruments and equipment. Successful dental restorations are based on the accuracy of the dental materials used in their fabrication, their dimensional stability, hardness, and tensile strength. Multiple studies indicate that dental impression materials and dental stones used in the fabrication of working models are affected by the concentration of chemical disinfectants in the solution, the disinfection methods used, such as immersing or spraying, and the contact time with the disinfectant.^30,31

Additionally, using the wrong disinfectant on dental prostheses and appliances can result in chemical absorption into the material, potentially causing allergic or adverse reactions in patients. This is especially true for resin-based items, such as complete and partial dentures, provisional restorations, nightguards, and sleep apnea appliances, since resin is a porous material that readily absorbs chemicals. These absorbed substances may interact with the oral environment and negatively impact the patient’s overall health.^32,33 Certain chemicals used in sterilization or disinfection are corrosive to different dental instruments and equipment, which weakens the instruments and creates microporous surfaces where infectious pathogens can “hide,” leading to deficiencies in sterilization.³⁴

Vaccination

Despite all infection control and disease transmission reduction protocols, DHCPs remain at high risk for contracting and transmitting infectious diseases. Research suggests that DHCPs are at risk for contracting the following infectious diseases: influenza, Hepatitis A, B, and C, measles, mumps, rubella, varicella, tuberculosis, and HIV. Most of those transmissions can be prevented by following immunization protocols established specifically for DHCPs by state, national, and professional agencies.¹¹

Nationally, the Advisory Committee on Immunization Practices (ACIP) develops vaccination recommendations for all healthcare workers, including DHCPs, based on their professional risks and evidence of potential disease transmission.³⁵ CDC recommends that dental professionals be vaccinated for or provide proof of immunity for influenza, Hepatitis B, measles, mumps, rubella, and varicella. Routine immunization for tuberculosis and Hepatitis A is not supported by evidence.¹¹ Currently, vaccines for HIV and Hepatitis C are not available; therefore, frequent monitoring by blood tests is recommended for DHCPs for early detection and treatment of those diseases. During the COVID-19 pandemic, all DHCPs were also required to be vaccinated against SARS-CoV-19. However, as of now, this vaccine is no longer required by OSHA but is highly recommended by the American Dental Association (ADA).³⁶ It is recommended that vaccinations be administered before exposure to potentially infectious materials; therefore, DHCPs are subject to vaccinations before the start of their employment or as students in dental and auxiliary programs. ADA acknowledges that multiple vaccine requirements can be present in dental settings. Some vaccines are recommended by state or national law, while additional vaccines may be required by employers.³⁷

Training and Education in Infection Prevention and Personnel Safety

As per CDC guidelines, each dental facility should have an appointed infection prevention coordinator, who must be properly trained in infection control procedures and maintain records for sterilization equipment maintenance, waterline testing, waste management, and be responsible for developing written policies for infection control procedures, and record-keeping of any possible bloodborne pathogen exposures and post-exposure protocols.¹⁹

Such policies and procedures should be specific to each facility, based on the volume of patients, procedures performed, number of employees, etc. Infection prevention policies must be reviewed annually to identify any possible shortcomings and rectify deficiencies, while also accommodating the use of new equipment, procedures, and protocols, and aligning them with the most recent recommendations from governmental agencies.¹⁹ Additionally, all DHCPs must be trained and certified on infection control and safety, which includes training on the OSHA Bloodborne Pathogens Standard and CDC guidelines for infection control in dental settings. States can have additional requirements for dental professionals to comply with, such as continuing education requirements that must be continuously satisfied on an annual or bi-annual basis by either all employees or limited to licensed dental professionals.

Documentation of such training and continuing education records must be submitted to the appointed infection prevention coordinator or human resources and provided to state and local agencies upon request.

Reduction in Disease Transmission Due to Technological Advances

The use of modern technology in dentistry, such as digital cameras, scanners, and CAD/CAM technology, not only increases productivity and the quality of dental work but also plays a role in reducing disease transmission.³⁸ However, it is important to note that the use of novel technologies only eliminates some steps in the chain of infection disease spreading process. Although technology plays a major role in dental care, it remains essential for DHCPs and DLTs to consistently practice proper hand hygiene, effective disinfection and sterilization procedures, and follow universal precautions.

Using digital impressions eliminates possible cross-contamination between the dental practice and the lab as compared to the use of conventional impression materials that require multiple steps in decontamination and infection control procedures, in addition to multiple team members handling the impressions and being exposed to potentially infectious agents. The high precision of digital impressions minimizes the need for retakes, which in turn reduces the number of patient visits.³⁸

Digital technology plays a key role in improving the efficiency of infection control surveillance and monitoring in dental settings. This includes digitizing sterilization records, spore testing results, waterline maintenance logs, and material safety data sheets, making them easily accessible during emergencies. Digital systems also support compliance by maintaining up-to-date employee training and vaccination records, as required by state and federal regulations. Additionally, technology can automate reminders for critical infection control tasks such as equipment maintenance, routine testing, record updates, and certification renewals.³⁹

Conclusion

Dental healthcare providers of all levels, from dentists to auxiliaries, are at high risk of contracting infectious diseases and spreading them to others. However, those risks can be significantly minimized by following standard precautions, infection control guidelines, and occupational safety protocols. Compliance with such policies by all dental professionals is of high importance. Infection prevention is regulated by local, state, and federal agencies and requires specific training, understanding of disease transmission processes, and critical points of cross-contamination between patients, providers, and technicians. Evolving modern technologies aid dental professionals in identifying risks, surveillance, monitoring, and the reduction of infectious disease transmission.

About the Authors

Khrystyna Vyprynyuk, MS, RDH
Assistant Professor, Dental Hygiene
New York City College of Technology
City University of New York
Brooklyn, NY

Laura Andreescu, MBA, CDT
Assistant Professor
Restorative Dentistry
New York City College of Technology
City University of New York
Brooklyn, NY

Disclosure: The authors report no conflicts of interest associated with this work.

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