8 Infection Control in Dental Radiography










70
8
Infection Control in Dental Radiography
EDUCATIONAL OBJECTIVES
Upon completing this chapter, the student will be able to:
1. Dene the key terms listed at the beginning of the chapter.
2. State the primary purpose of infection control procedures,
discuss the signicance of cross-contamination in the
oce setting, and summarize the signicance of taking an
accurate medical history of your patient.
3. Dene the meaning of a pathogen, and explain its relevance
to an infection control protocol in the dental oce.
4. Describe what the term personal protective equipment
(PPE) means in reference to dental oce infection control
programs, as well as what the advised PPE requirements are
for dental radiography.
5. Discuss the barriers used for sterilization, disinfection,
digital radiography, lm packets, processing solutions, and
panoramic radiography in the dental oce. In addition,
perform the following procedures and discuss infection
control protocol for each:
• ChairsideExposureProcedures
• ProcessingProcedures(ConventionalRadiography)
• ProcedureforDaylightLoaders
6. Decide when antibiotic prophylaxis is required for dental
radiographic procedures and what vaccinations are required
for dental personnel.
KEY TERMS
acquired immunodeciency syndrome
(AIDS)
antibiotic prophylaxis
antiseptics
autoclaving
barrier envelope
Centers for Disease Control and
Prevention (CDC)
cross-contamination
disinfection
hepatitis
human immunodeciency virus
(HIV)
immunizations
infection
microorganism
Occupational Safety and Health
Administration (OSHA)
pathogen
personal protective equipment (PPE)
semi-critical devices
sterilization
universal precautions
vaccination
and herpes always have been a risk for dental professionals,
but it took the fatal consequences of AIDS in the 1980s
to heighten the interest and awareness of the public, the
government, and the profession to the importance of infec-
tion control in the dental oce. Federal and state agencies
at all levels are currently imposing requirements for oce
procedures and required courses in infection control. As a
result, dental personnel are encouraged to employ universal
infection control procedures when dealing with all of their
dental patients.
Infection Control in Dental Practice
Any comprehensive infection control policy in dentistry
must include protocols for radiology, including both chair-
side technique and, when applicable, darkroom procedures
as well. Radiology is not exempt from infection control,
even though radiographic procedures are not considered
to be “invasive” procedures and do not involve the aerosol
Introduction
Infection control has become a major concern of patients,
regulatory agencies, and health care workers in the practice
of dentistry. e primary purpose of infection control
procedures is to prevent infectious disease transmission.
Disease transmission in the dental practice can occur from a
dental professional to a patient, from a patient to the dental
professional, or even between patients. e dental profes-
sional should practice infection control at all times, because
dental personnel and patients are at risk from pathogens. A
pathogen is a microorganism capable of causing disease.
Pathogens can be transmitted by infection from cuts,
breaks in the skin, and contact with body secretions and
inhalants. e emergence and identication of acquired
immunodeciency syndrome (AIDS) in 1981, the highly
infectious hepatitis B and C viruses (HBV and HCV), and
the resurgence of tuberculosis brought this public health
issue to the forefront. Diseases such as tuberculosis, hepatitis,

71CHAPTER 8 Infection Control in Dental Radiography
noncritical instrument: An instrument that does not come
in contact with mucous membranes (e.g., position-
indicating device [PID], exposure button, control panel)
occupational exposure: Contact of the skin or mucous
membranes by blood or other infectious material that
results from performing dental and other health care
procedures
parenteral exposure: Exposure to blood or other infectious
material that results in skin puncture
semi-critical instrument: An instrument that comes in
contact with the mucous membrane but does not pen-
etrate (e.g., x-ray receptor holding device)
sterilization: e process used to destroy all pathogens,
including highly resistant bacteria and spores
universal precautions: An infection control protocol that
is followed for all patients regardless of their history and
clinical condition
Patient Medical History
e dentist or dental professional should document every
patient’s current medical history. is history should be
obtained at the initial or recall visit using a questionnaire
and/or direct questioning of the patient. Information
gained by the history alerts the dental team to the presence
or history of infectious disease or to potentially high-risk
situations. Unfortunately, many potentially infectious
patients cannot be identied by history or examination.
us, a rational infection control policy should not distin-
guish between patients who are known to be infected and
those who are not. Every patient should be treated in the
same manner, with universal precautions carried out at
all times. ere should be no exceptions and therefore no
surprises.
Sources of Infection
rough contact with saliva, blood, and nasal and respiratory
secretions, many instruments and pieces of equipment can
become the means of pathogen transmission. A pathogen
is a microorganism that can cause disease. After the dental
professional’s gloves are contaminated by oral cavity uids
during radiographic procedures, everything that person
touches is a possible transmitter of pathogens. Our concern,
then, is with receptor-holding devices, instruments, recep-
tors (including lms and digital sensors), the x-ray machine,
PID, tube head, control panel, exposure switch, clothing,
countertops, dental chair, lead apron, light handle, walls,
doorknobs, processors, patient records, and the computer
keyboard. In short, any object that the operator touches after
placing the packet in the patient’s mouth can be considered
contaminated and a source of transmission to the operator
or other patients. On the other hand, any object that the
operator touches before working in the mouth is a potential
source of transmission to the patient. us, barriers to the
transmission of infective microorganisms must be used.
Personal barriers or personal protective equipment (PPE)
spray produced by the dental handpiece, needles, or the
cutting of tissue and splatter of blood. Infectious disease
can be transmitted by the cross-contamination of equip-
ment, supplies, and receptors used to expose or process
radiographs. In addition, dental radiographic procedures
are in almost all cases performed in the same dental chairs
and units that are used for more invasive procedures, with
the potential for cross-contamination. Also, lead aprons and
thyroid collars should be disinfected after each use to avoid
contamination from one patient to the next. e Ameri-
can Dental Association (ADA), the Centers for Disease
Control and Prevention (CDC), and the Occupational
Safety and Health Administration (OSHA) all state that
gloves must be worn when contact with blood, saliva, or
other potentially infectious material, items, or surfaces is
anticipated. Masks and eyewear are technically required
only when splatter is anticipated. However, masks, eyewear,
and protective clothing should potentially be used at all
times, because these precautions will prevent potential
cross-contamination where applicable.
NOTE
Personal protective equipment (PPE), such as gloves and
protective clothing, are required when contact with blood or
other bodily uids is anticipated. However, protective eyewear
and masks are considered optional for dental imaging
procedures when aerosol and spatter of saliva and blood do
not usually occur. There is a possibility of facial contact with
blood and saliva during radiographic procedures, however.
Therefore, it is recommended to wear a mask and protective
eyewear, because it is better to be safe than sorry.
If infection control is understood and practiced, then
patients, coworkers, and dental care providers themselves
can be protected from harm. e objective is to be educated
with the most up-to-date procedures so that work can be
conducted in the safest possible manner. Proper infection
control procedures should be followed before, during, and
after dental radiographic exposures are made. Infection
control steps for chairside dentistry should be followed in
addition to the specic steps advised for dental radiographic
procedures.
e following is a list of terms and denitions that are
used in this discussion of infection control in the dental
setting:
antiseptic: A substance that inhibits the growth of bacteria
autoclaving: e process of sterilization using steam
barrier: A substance used to protect the patient or worker
from infective or contaminated substances
blood-borne pathogen: A pathogen present in blood that
can cause infection in humans
critical instrument: An instrument used to penetrate soft
tissue or bone
disinfection: e process of destroying disease-causing
microorganisms by physical or chemical means (e.g.,
hand washing)

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708 Infection Control in Dental RadiographyEDUCATIONAL OBJECTIVESUpon completing this chapter, the student will be able to:1. Dene the key terms listed at the beginning of the chapter.2. State the primary purpose of infection control procedures, discuss the signicance of cross-contamination in the oce setting, and summarize the signicance of taking an accurate medical history of your patient.3. Dene the meaning of a pathogen, and explain its relevance to an infection control protocol in the dental oce.4. Describe what the term personal protective equipment (PPE) means in reference to dental oce infection control programs, as well as what the advised PPE requirements are for dental radiography.5. Discuss the barriers used for sterilization, disinfection, digital radiography, lm packets, processing solutions, and panoramic radiography in the dental oce. In addition, perform the following procedures and discuss infection control protocol for each:• ChairsideExposureProcedures• ProcessingProcedures(ConventionalRadiography)• ProcedureforDaylightLoaders6. Decide when antibiotic prophylaxis is required for dental radiographic procedures and what vaccinations are required for dental personnel.KEY TERMSacquired immunodeciency syndrome (AIDS)antibiotic prophylaxisantisepticsautoclavingbarrier envelopeCenters for Disease Control and Prevention (CDC)cross-contaminationdisinfectionhepatitishuman immunodeciency virus (HIV)immunizationsinfectionmicroorganismOccupational Safety and Health Administration (OSHA)pathogenpersonal protective equipment (PPE)semi-critical devicessterilizationuniversal precautionsvaccinationand herpes always have been a risk for dental professionals, but it took the fatal consequences of AIDS in the 1980s to heighten the interest and awareness of the public, the government, and the profession to the importance of infec-tion control in the dental oce. Federal and state agencies at all levels are currently imposing requirements for oce procedures and required courses in infection control. As a result, dental personnel are encouraged to employ universal infection control procedures when dealing with all of their dental patients.Infection Control in Dental PracticeAny comprehensive infection control policy in dentistry must include protocols for radiology, including both chair-side technique and, when applicable, darkroom procedures as well. Radiology is not exempt from infection control, even though radiographic procedures are not considered to be “invasive” procedures and do not involve the aerosol IntroductionInfection control has become a major concern of patients, regulatory agencies, and health care workers in the practice of dentistry. e primary purpose of infection control procedures is to prevent infectious disease transmission. Disease transmission in the dental practice can occur from a dental professional to a patient, from a patient to the dental professional, or even between patients. e dental profes-sional should practice infection control at all times, because dental personnel and patients are at risk from pathogens. A pathogen is a microorganism capable of causing disease. Pathogens can be transmitted by infection from cuts, breaks in the skin, and contact with body secretions and inhalants. e emergence and identication of acquired immunodeciency syndrome (AIDS) in 1981, the highly infectious hepatitis B and C viruses (HBV and HCV), and the resurgence of tuberculosis brought this public health issue to the forefront. Diseases such as tuberculosis, hepatitis, 71CHAPTER 8 Infection Control in Dental Radiographynoncritical instrument: An instrument that does not come in contact with mucous membranes (e.g., position-indicating device [PID], exposure button, control panel)occupational exposure: Contact of the skin or mucous membranes by blood or other infectious material that results from performing dental and other health care proceduresparenteral exposure: Exposure to blood or other infectious material that results in skin puncturesemi-critical instrument: An instrument that comes in contact with the mucous membrane but does not pen-etrate (e.g., x-ray receptor holding device)sterilization: e process used to destroy all pathogens, including highly resistant bacteria and sporesuniversal precautions: An infection control protocol that is followed for all patients regardless of their history and clinical conditionPatient Medical Historye dentist or dental professional should document every patient’s current medical history. is history should be obtained at the initial or recall visit using a questionnaire and/or direct questioning of the patient. Information gained by the history alerts the dental team to the presence or history of infectious disease or to potentially high-risk situations. Unfortunately, many potentially infectious patients cannot be identied by history or examination. us, a rational infection control policy should not distin-guish between patients who are known to be infected and those who are not. Every patient should be treated in the same manner, with universal precautions carried out at all times. ere should be no exceptions and therefore no surprises.Sources of Infectionrough contact with saliva, blood, and nasal and respiratory secretions, many instruments and pieces of equipment can become the means of pathogen transmission. A pathogen is a microorganism that can cause disease. After the dental professional’s gloves are contaminated by oral cavity uids during radiographic procedures, everything that person touches is a possible transmitter of pathogens. Our concern, then, is with receptor-holding devices, instruments, recep-tors (including lms and digital sensors), the x-ray machine, PID, tube head, control panel, exposure switch, clothing, countertops, dental chair, lead apron, light handle, walls, doorknobs, processors, patient records, and the computer keyboard. In short, any object that the operator touches after placing the packet in the patient’s mouth can be considered contaminated and a source of transmission to the operator or other patients. On the other hand, any object that the operator touches before working in the mouth is a potential source of transmission to the patient. us, barriers to the transmission of infective microorganisms must be used. Personal barriers or personal protective equipment (PPE) spray produced by the dental handpiece, needles, or the cutting of tissue and splatter of blood. Infectious disease can be transmitted by the cross-contamination of equip-ment, supplies, and receptors used to expose or process radiographs. In addition, dental radiographic procedures are in almost all cases performed in the same dental chairs and units that are used for more invasive procedures, with the potential for cross-contamination. Also, lead aprons and thyroid collars should be disinfected after each use to avoid contamination from one patient to the next. e Ameri-can Dental Association (ADA), the Centers for Disease Control and Prevention (CDC), and the Occupational Safety and Health Administration (OSHA) all state that gloves must be worn when contact with blood, saliva, or other potentially infectious material, items, or surfaces is anticipated. Masks and eyewear are technically required only when splatter is anticipated. However, masks, eyewear, and protective clothing should potentially be used at all times, because these precautions will prevent potential cross-contamination where applicable.NOTEPersonal protective equipment (PPE), such as gloves and protective clothing, are required when contact with blood or other bodily uids is anticipated. However, protective eyewear and masks are considered optional for dental imaging procedures when aerosol and spatter of saliva and blood do not usually occur. There is a possibility of facial contact with blood and saliva during radiographic procedures, however. Therefore, it is recommended to wear a mask and protective eyewear, because it is better to be safe than sorry.If infection control is understood and practiced, then patients, coworkers, and dental care providers themselves can be protected from harm. e objective is to be educated with the most up-to-date procedures so that work can be conducted in the safest possible manner. Proper infection control procedures should be followed before, during, and after dental radiographic exposures are made. Infection control steps for chairside dentistry should be followed in addition to the specic steps advised for dental radiographic procedures.e following is a list of terms and denitions that are used in this discussion of infection control in the dental setting:antiseptic: A substance that inhibits the growth of bacteriaautoclaving: e process of sterilization using steambarrier: A substance used to protect the patient or worker from infective or contaminated substancesblood-borne pathogen: A pathogen present in blood that can cause infection in humanscritical instrument: An instrument used to penetrate soft tissue or bonedisinfection: e process of destroying disease-causing microorganisms by physical or chemical means (e.g., hand washing) 72 CHAPTER 8 Infection Control in Dental Radiographyor facility and should ideally be laundered immediately after professional use if it is not disposable.Masks/Eye Protection/Plastic Face ShieldsFace masks and protective eyewear (preferably with solid side shields) or plastic face shields that extend to the chin should be worn by dental professionals whenever they perform any intraoral radiographic procedures. Masks and eyewear or face shields should be in place before a practitioner washes hands and dons gloves, and should not be removed until the unit is cleaned after the completion of patient care.Gloves/Hand WashingDental professionals must wear gloves when they perform intraoral procedures; there is no exception to this rule. Before putting on gloves, hands should be washed with an antimicrobial soap or a hand sanitizer (Fig. 8.2). is process should be repeated after gloves are removed at the completion of the patient’s treatment. While gloved, one should not touch items, such as pens, pencils, x-ray mounts, charts, computer keyboards/mouse pads, or telephones. Paper towels may be used as barriers between these items and the gloved hands.BarriersAny object that the operator touches after placing the recep-tor in the patient’s mouth must be covered with a removable barrier or disinfected after the patient leaves. A good maxim to remember is, “e less you touch, the less you have to worry about.” ere is a complete line of dental wrap with adhesive backing made specically for barriers. Barrier mate-rial should be placed over the chair, headrest, countertop, arm and PID (“collimator”) of the x-ray machine, control panel, computer keyboard, and exposure button before the includes gloves, masks, protective eyewear, protective cloth-ing, and surface coverings. If contamination does occur, as it does in the dental oce, steps must be taken to remove or destroy the pathogen and the contaminated item to prevent further transmission.PersonnelDental personnel always should wear gloves, masks, protec-tive eyewear and protective clothing (PPE) when working on patients (Fig. 8.1). Just as there is no excuse for not protecting yourself from radiation exposure (i.e., by stand-ing 6 feet away from the x-ray machine), there is no excuse for not protecting oneself from infection. Blood is the most common and easily recognized transmission route of infectious microorganisms (i.e., microorganisms associated with human immunodeciency virus [HIV], HBV, and HCV). Although HIV has been isolated in the saliva of some patients, saliva alone is not considered to be a risk for HIV transmission, but because saliva is often contaminated with blood, there is a potential for transmission. It is true that no cases of HIV transmission have been documented via the salivary route by casual contact, but this should not be an excuse for not wearing gloves, masks, and protective clothing and eyewear. Saliva can be contaminated by blood and therefore poses the potential for transmission.Protective ClothingAny dental professional involved in direct patient care should wear a clean, long-sleeved, three-quarter-length uniform, jacket, or disposable gown with a closed collar. Protective clothing should not be worn outside of the dental care area • Figure 8.1 Operator exposing radiographs while wearing gloves, eyeglasses, mask, and protective clothing. • Figure 8.2 Instant hand sanitizer. 73CHAPTER 8 Infection Control in Dental Radiographyare examples of disinfectants commonly used in the dental oce.“Cold sterilization” of instruments with quaternary ammonium compounds or glutaraldehyde is still used in the dental oce but requires up to 6 hours of immersion to achieve sterilization. is method does not seem practical in a busy oce and might lead to shortcutting time require-ments. Furthermore, some instruments, such as plastic receptor holders, bite blocks, or localizing rings, may be damaged if not handled correctly during heat sterilization. e majority of radiographic devices manufactured today are autoclavable and are clearly marked as such.Antiseptics are agents used on human tissue that are either bacteriostatic or bacteriocidal. In dentistry, they are used mainly for hand washing. In dental radiography, the use of sterilization, disinfection, and antiseptic agents results in a rational, workable infection control policy.patient is seated (Figs. 8.3 to 8.5). e barriers are easily removed after the radiographic procedure is completed. If barriers are not used, these objects must be disinfected after the radiographic procedure is completed. Disinfecting solutions, such as iodophor or any other Environmental Protection Agency–registered chemical germicide, have the drawback that they may not reach irregular surfaces of the dental x-ray machine and have the potential to aect electrical connections in the head of the machine (Fig. 8.6). ese irregular surfaces should be covered as opposed to sprayed with a disinfectant to prevent cross-contamination.Sterilization and DisinfectionSterilization produces the absence of all microorganisms, including spores. e most common method of sterilization used in the dental oce is steam autoclaving. e radio-graphic instruments are sterilized in bags or appropriate cassettes in the same manner as other dental instruments.Disinfection is the process that results in the absence of pathogenic organisms but not spores. Disinfecting agents are usually employed on surfaces but not on human tissue. Iodophors, chlorines, and synthetic phenolic compounds • Figure 8.3 A plastic bag is slipped over the tubehead, pulled tight, and secured. (From Bird DL, Robinson DS: Modern Dental Assisting, ed 12, St Louis, 2018, Elsevier.)• Figure 8.4 Plastic wrap covering the position-indicating device (PID). (From Langlais RP, Miller CM: Exercises in Oral Radiology and Interpretation, ed 5, St Louis, 2017, Elsevier.)• Figure 8.5 Plastic wrap covering the control panel and exposure switch. (From Bird DL, Robinson DS: Modern Dental Assisting, ed 12, St Louis, 2018, Elsevier.)• Figure 8.6 Barriers are preferred over disinfecting sprays that may not reach all surfaces or may affect electrical connections. 74 CHAPTER 8 Infection Control in Dental RadiographyFilm PacketsOther than the operator’s hands, the lm packet or digital sensor is the main vector of cross-contamination. e recep-tor remains in the patient’s mouth; when removed, it is coated with saliva or possibly with blood.In the case in which the receptor is a lm packet (as opposed to a digital sensor), it is handled carefully in the Digital RadiographyDigital radiography receptor (directly wired or wireless sensors and phosphor plates) are considered to be semi-critical devices, because they are used intraorally and come into contact with mucous membranes. e direct digital sensors (charge-coupled device and complementary metal oxide semiconductor sensors) and phosphor plate sensors (indirect digital sensors) cannot be placed into an autoclave or immersed in contact disinfectants. It is recommended that U.S. Food and Drug Administration–approved hygienic barriers must be used to meet infection control standards and prevent cross-contamination (Fig. 8.7). It is important to cover the digital sensor and any cords that may come into contact with intraoral surfaces of contaminated hands (gloves). Finger cots can be used in addition to the barrier sheaths for added protection. It is also important to adequately clean and disinfect the sensor before and after use.• Figure 8.7 Digital sensor with barrier sheath in place. NOTETo disinfect the sensor, only disinfecting wipes or a solution containing intermediate-level disinfectant should be used. It is also important to follow the manufacturer’s directions for cleaning and disinfecting. Some manufacturers warn against using chlorine-based products (i.e., bleach), because they may be too corrosive for the sensors. Furthermore, digital sensors should never be soaked overnight, and barrier sheaths or envelopes must also never be reused. Care should be taken to clean, disinfect, and cover the computer keyboard/mouse being used according to infection control protocols as well.A• Figure 8.8 Barrier envelope. A, With lm packet. B, In lm holder. (A, Courtesy Carestream Dental, Rochester, NY.)operatory and then transported to the darkroom. e fol-lowing three methods can theoretically prevent transmission of microorganisms by the lm packet to other parts of the operatory or the darkroom: (1) sterilization or disinfection of the exposed packet, (2) use of barrier protection for the packet, and (3) proper handling technique.1. Sterilization and disinfection of the lm packet are not advised, because they are impractical and time-consuming and may degrade or ruin the radiographic image. Autoclaving the lm packet can also destroy the image. Immersing the packet in a disinfecting solution for the required time results in penetration of the solu-tion to the lm emulsion. us, neither sterilization nor disinfection is recommended.2. Barrier envelopes for lm packets are available in the dental market for x-ray lms and may be purchased with the lm packet already inserted into the barrier envelopes, or the barrier envelopes may be purchased separately and individual lm packets may be inserted in them before exposure (Fig. 8.8).e lm packet is exposed in the barrier envelope, dried of saliva, and then brought to the darkroom in some type of a receptacle without the barrier envelope. e operator wears gloves to open the barrier envelope, taking care not to touch the lm packet, and the packet is allowed to drop into a clean receptacle (i.e., cup) or surface. e gloves and the barrier envelope are then discarded, and the operator opens the lm packet and processes the lm with either bare hands or new, unused gloves.3. If the barrier lm packet technique is not used, after the exposure is made, the lm packet that is contaminated by saliva or blood should be wiped dry and placed in a receptacle that is outside the operatory and carried to the darkroom when all the exposures have been made. 75CHAPTER 8 Infection Control in Dental Radiographycommon misconception that they do. Any contaminated lm that is processed emerges from the processing procedure still contaminated. It has been shown that microorganisms can remain viable on radiographic equipment for at least 48 hours. In automatic processors, the rollers and tracks can be contaminated by the lm, as can the lm hangers in manual processing.is lm transport to the darkroom can be performed after the contaminated gloves are disposed of and a clean receptacle (i.e., cup) carrying the contaminated lms are brought to the darkroom. Once operators are in the darkroom and have put on new gloves, they can open the lm packets under safelight conditions. ey should take care not to touch the lms as they are dropped onto a clean surface (Fig. 8.9). e gloves that they handled the contaminated packets with are then discarded, and the lms are processed either manually or automatically. If there are two people in the darkroom (admittedly, this is not common in most oces), one gloved person can open the contaminated packet and the other can remove the lm from within the packet without touch-ing the outside (Fig. 8.10). is process will also prevent contamination of the lm.Processing Solutionse developing and xing solutions used in the darkroom have not been shown to act as sterilizing agents. It is a • Figure 8.9 Opening contaminated lm packet in the darkroom. • Figure 8.10 A and B, Two-operator technique for removing lm from a contaminated packet. PROCEDURE 8.1 Chairside Exposure Procedures1. Cover all appropriate surfaces with a plastic barrier. This should include but not be limited to the PID and arm of the x-ray machine, the control panel, the exposure button, the computer keyboard/mouse, and the working surfaces where unexposed receptors are placed (Fig. 8.11). Plan in advance, setting out all anticipated supplies (receptors, receptor holders, cotton rolls, and so on).2. Seat the patient and drape with the lead apron and thyroid collar in the appropriate manner. Make sure that the protective apron and thyroid collar have been cleaned and disinfected before placing them on the patient.3. Wash hands thoroughly with soap or an approved instant hand sanitizer (e.g., Purell) and put on gloves.4. Make the required exposures, taking care to touch only the covered surfaces. If the procedure is interrupted and Continued 76 CHAPTER 8 Infection Control in Dental Radiographyyou have to leave the room and touch anything, remove the gloves, dispose of them, and put on a new pair before resuming work. Each exposed receptor should be wiped dry of saliva and placed in a clean receptacle (i.e., cup) outside of the cubicle.5. If no other dental procedures are to be done, dismiss the patient. Dispose of all contaminated barriers and supplies in the operatory; then, disinfect the lead apron/collar and other appropriate surfaces.6. Remove the contaminated gloves.o the contaminated gloves and feed the lm into the uptake slots. An operator who must use a daylight loader when the barrier packets are not available should follow the protocol found in Procedure 8.3.Panoramic RadiographyBecause panoramic radiography is an extraoral procedure, fewer areas are contaminated by the patient’s saliva. In both conventional and digital panoramic radiography, the patient Automatic Processing (Conventional Radiography)Operators should load lm into an automatic processor with the same concern and method for avoiding cross-contamination as with manual processing lm hangers. e problem is with the automatic processors used with daylight loaders. Use of daylight loaders creates a situation in which it is very dicult to avoid contamination as a result of the tight-tting hand baes, which serve as a source of cross-contamination (Fig. 8.12). is is not the case if one is using the barrier packs. It is also very dicult to remove the lm from the lm packet and to put on one’s gloves within the conned space of the daylight loader, then take • Figure 8.11 Plastic wrap covering necessary items on a work surface. PROCEDURE 8.2 Processing Procedures (Conventional Radiography)1. Put on new gloves.2. Under safelight conditions with gloved hands, remove the lms from the lm packet or the lm packets from the barrier envelopes by allowing them to drop onto a clean surface. Do not touch the lm with gloved hands. The gloves are considered to be contaminated because they touched the lm packet.3. Dispose of the lm packet wrappers and carrying cup and remove and dispose of the gloves.4. Process the uncontaminated lm on the clean surface either manually or automatically.5. The lm is not contaminated; thus, gloves are not needed for processing or mounting.• Figure 8.12 The sleeves of an automatic processor have been contaminated by the operator’s contaminated gloves. PROCEDURE 8.1—cont’dChairside Exposure Procedures 77CHAPTER 8 Infection Control in Dental RadiographyPROCEDURE 8.3 Procedure for Daylight Loaders1. Prepare the interior of the daylight loader by placing a barrier on the bottom surface. Place the cup with the exposed lm packets, a pair of gloves, and a second cup inside the daylight loader and then close the top of the daylight loader.2. Place clean hands through the sleeve bafes and put on the gloves.3. Open packets, allowing the lms to drop into the second cup.4. Remove gloves and place the uncontaminated lms in the processing slots; then, remove ungloved hands through the sleeves.5. Open the top of the loader and wrap all trash in the barrier and remove.6. Wash hands.radiographs; however, because of the immense risk to the patient, it is prudent to provide prophylaxis if any bleed-ing is expected. In clinical practice, however, most patients needing antibiotic prophylaxis will have been provided with prophylaxis, because it is rare that the only procedure done at a specic appointment is the taking of radiographs.ImmunizationAll dental personnel should have the appropriate immu-nizations (e.g., tetanus, inuenza, varicella), including that for the hepatitis B virus. OSHA’s standard covering blood-borne pathogens requires health care employers to oer a three-injection HBV vaccination series free to all employees exposed to blood or other potentially infectious uids or materials. e OSHA standard also states that if routine booster doses of the hepatitis vaccine are recom-mended at some future date, then the employer also should make these boosters available to employees at no cost.bite block should be covered by a plastic barrier cover (Fig. 8.13) and the lead apron should be disinfected. Plastic barrier wrap should also be used on the chin rest, ear rods, patient handgrips, the control panel, and the computer keyboard/mouse. In conventional panoramic radiography, processing does not present a problem, because the cas-sette does not contact the patient; thus, the procedure for preventing lm contamination is not necessary. e only possible contaminant in the darkroom would be the operator’s gloves. ese gloves should be removed before the cassette is taken from the panoramic unit.Antibiotic ProphylaxisIt is an accepted and required procedure to provide pro-phylaxis with antibiotics for certain patients before dental procedures. Any procedure, including probing, that might produce bleeding should be considered invasive. e ques-tion then arises regarding whether intraoral radiography is an invasive procedure, because in rare instances it may produce bleeding. e American Medical Association suggests that prophylaxis is not necessary before taking • Figure 8.13 The patient bite block is covered by a plastic barrier cover. Chapter Summary• e primary purpose of infection control proceduresin a dental practice is to prevent infectious disease transmission.• Federal and state agencies at all levels are currentlyimposing requirements for dental oce procedures and required courses in infection control.• Infectious disease can be transmitted by the cross-contamination of equipment, supplies, and receptors used to expose or process radiographs.• Every dental patient should be treated in the samemanner, with universal precautions carried out at all times.• Any object that the operator touches after placing thereceptor in the patient’s mouth must be covered with a removable barrier or disinfected after the patient leaves.• Digitalsensorsandcomputerkeyboardsshouldbewipedand covered before use and wiped after use as well.• Barrierenvelopesareusedtopreventcross-contaminationby the lm packet, and there are various ways of handling lms during processing, depending on whether they have barrier envelopes on them or not.• All dental personnel should practice the appropriateinfection control procedures for all dental procedures, including dental radiography. 78 CHAPTER 8 Infection Control in Dental RadiographyChapter Review QuestionsMultiple Choice1. A pathogen is: a. An organism that attaches itself to another organism b. An autoimmune mechanism for disease c. A microorganism capable of causing disease d. A pathologic psychosis e. A person with a serious pathology2. e personal protective equipment (PPE) strongly sug-gested for dental professionals to wear while exposing digital radiographs is: a. A mask b. Protective eyewear c. Protective clothing d. Gloves e. All of the above3. Which of the following statements regarding “barrier envelopes” is false? a. Some lms come with barrier envelopes. b. You can manually place a lm packet in a barrier envelope. c. You can remove the barrier envelope and process with the same gloves. d. Digital sensors are covered with barrier sheaths, which are comparable in design and use to the barrier enve-lopes used with conventional lm. e. Barrier envelopes help protect the lm packet from contamination.4. e American Medical Association suggests that antibi-otic prophylaxis is: a. Necessary for all patients b. Necessary when bleeding is expected c. Not necessary for radiographic procedures d. a and b only e. b and c only5. e primary purpose of infection control procedures in a dental practice is to prevent infectious disease transmis-sion. e main vector for cross-contamination in dental radiography other than the operator’s glove is the image receptor. a. Both statements are true. b. Both statements are false. c. e rst statement is true, and the second statement is false. d. e rst statement is false, and the second statement is true. e. Not enough information is given to answer this ques-tion correctly.Critical Thinking Exercises1. A new patient who requires antibiotic prophylaxis comes to your oce for the rst time. e only procedure that your patient is currently scheduled for is digital radiographs. e patient refuses to take the premedica-tion “just for radiographs to be taken.” Discuss how you would handle this situation, including the following: a. e American Medical Association’s suggestion on this matter b. e procedure(s) that this patient is scheduled for c. e need for a clinical oral examination of the patient’s periodontium d. e risks the patient will be taking if not premedicated e. e rationale behind your decision-making process in this particular situation2. You are scheduled to expose a full series of radiographs on your patient utilizing lm-based dental radiography. e patient has no known infectious diseases. You will be processing the radiographs in an automatic processor with a daylight loader. Describe the infection control steps you will take to protect your patient and yourself. Include in your discussion: a. Universal precautions b. e handling of the exposed lm packets with barrier envelopes while exposing the radiographs c. e handling of the exposed lm packets during the processing procedure d. e PPE that you will be wearing e. e preparation of the operatory f. What you will do with the XCP receptor-holding devices when you have completed the radiographic procedureBibliographyAmerican Academy of Oral and Maxillofacial Radiology infection control guidelines for dental radiographic procedures, Oral Surg Oral Med Oral Pathol 73:248–249, 1992.Bartoloni JA, Chariton DG, Flint DJ: Infection control practices in dental radiology, Gen Dent 51:264–271, 2003.Eastman Kodak Co: Infection in modern practice, Rochester, NY, 1999, Health Science Division.Glass BJ: Infection control in dental radiology. Current and future, N Y State Dent J 60:42–45, 1994.Hastreiter RJ, Jiang P: Do regular dental visits aect the oral health care provided to people with HIV, J Am Dent Assoc 133:1343–1350, 2002. 79CHAPTER 8 Infection Control in Dental RadiographyKohn WG, Collins AS, Cleveland JL, et al: Guidelines for infection control in dental health-care settings—2003, MMWR Recomm Rep 52(RR–17):1–61, 2003.Langland OE, Langlais RP: Principles of dental imaging, Baltimore, MD, 1997, Williams & Wilkins.ompson EM, Johnson ON: Essentials of dental radiography for dental assistants and hygienists, ed 9, Upper Saddle River, NJ, 2012, Pearson Education, Inc.White SC, Pharoah MJ: Oral radiology: Principles and interpretation, ed 7, St Louis, MO, 2013, Mosby.Iannucci JM, Howerton LJ: Dental radiography: Principles and tech-niques, ed 5, St Louis, MO, 2016, Elsevier Saunders.Infection control recommendations for the dental oce and the dental laboratory. ADA Council on Scientic Aairs and ADA Council on Dental Practice, J Am Dent Assoc 127:672–680, 1996.Jones GA, Woods MA, Burton EL, et al: Radiographic protocol for patients needing antibiotic prophylaxis: dental schools report no consensus, J Am Dent Assoc 125:602–604, 606, 1994.Kohn WG, Harte JA, Malvitz DM, et al: Guidelines for infection control in dental health care settings—2003, J Am Dent Assoc 135:33–47, 2004.

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