Frequently Asked Questions - Infection Prevention and Control

To prevent percutaneous injuries, contaminated instruments must be placed in a puncture-resistant covered container or locked cassette at the point of use and then transported to the instrument reprocessing area.

No - the College does not require routine water quality testing. For dental offices using a municipal water supply, this should not be necessary, unless the municipality has indicated otherwise. The office is responsible for following the requirements set out in the College’s IPAC Standard regarding the maintenance of dental unit waterlines, such as regularly flushing and purging waterlines (see page 30).

For offices using closed or other water delivery systems, the manufacturer’s instructions related to dental units and equipment must be followed for daily and weekly maintenance.

In the case of a boil water advisory, Public Health authorities may require specific measures. Please see page 30 of the College IPAC Standard.

Contact a representative from Public Health Ontario or your local Public Health Unit (LPHU) for further guidance.

Clinical contact surfaces include (but are not limited to):

• chair controls and switches
• light handles and switches
• radiography equipment
• chairside computer keyboards and monitors
• reusable containers of dental materials
• drawer and faucet handles
• countertops
• pens
• telephones
• doorknobs.

Clinical contact surfaces should be cleaned and disinfected between patients and at the end of the workday, using an appropriate hospital-grade low-level disinfectant (i.e. has a DIN from Health Canada). To facilitate this, treatment areas must be well-organized and kept free of unnecessary equipment and supplies, especially on countertops. Ideally, clinical contact surfaces and equipment should be disinfected with a cloth and disinfectant, allowing adequate wet contact time with the disinfectant, as described in the manufacturers’ instructions for use.

Disinfectant wipes are a convenient option, but it may be difficult to achieve adequate wet contact time.

Accordingly, when using disinfectant wipes:

• the active ingredient must be an appropriate hospital-grade disinfectant;
• they must be kept wet and discarded if they become dry;
• multiple wipes may be required for large surfaces and equipment.

Alternatively, clinical contact surfaces and equipment can be protected from contamination by the use of barriers. Barriers are particularly effective for those surfaces that are difficult to clean and disinfect, due to their shape, surface or material characteristics. Suitable barrier materials include:

• clear plastic wrap
• plastic bags
• plastic sheets
• plastic tubing
• plastic-backed paper
• other moisture-proof materials.

Since barriers can become contaminated during dental procedures, they must be removed, using gloves, and discarded between patients. Following barrier removal, the underlying surfaces must be examined to ensure they did not inadvertently become contaminated. Those that did must be cleaned and disinfected. Otherwise, clean barriers must be placed before seating the next patient. At the end of the workday, remove all barriers and clean these surfaces.

Hand hygiene is necessary:

• Before an aseptic procedure
• Before putting on gloves
• After glove removal
• Before and after direct contact with individual patients
• After contact with environmental surfaces, instruments or other equipment in the dental operatory
• After contact with dental laboratory materials or equipment
• Before leaving the clinical operatory
• Before eating or drinking
• Whenever in doubt

If hands are NOT visibly soiled (i.e. the majority of instances), the use of a 70-90% alcohol-based hand rub is the preferred method of hand hygiene. It is more effective than washing with soap and water when hands are not visibly soled and takes less time.

If hands are visibly soiled (including with powder from gloves) or after performing body functions then hands should be washed with plain or antimicrobial soap and running water.

Use professional judgment for either procedure. If you think your hands have accidentally become contaminated with body fluids, wash with soap and water to remove organic matter. However, there is sufficient evidence that alcohol-based hand rubs are superior to washing with soap and water, except in cases where the hands are visibly soiled or contaminated with body fluids.

Long nails are difficult to clean, may pierce gloves and harbour more microorganisms than short nails. Chipped nail polish or nail polish worn longer than 4 days may harbour microorganisms that are not removed by hand washing, even with surgical hand scrubs. Artificial nails and nail enhancements harbour microorganisms and are more difficult to clean than natural nails.

All OHCWs having direct contact with a patient must keep nails clean and short. Nail polish, if worn, must be fresh and free of cracks or chips. Artificial nails and nail enhancements must not be worn

Before performing hand hygiene, hand jewelry must be removed and arm jewellery, including watches, must be either removed or pushed up above the wrist. Rings should not be worn.

Blood-borne pathogens, such as HBV, HCV and HIV, can be transmitted to OHCWs through occupational exposures to blood, saliva and other body fluids. Significant exposures must be handled in a prompt and organized fashion. For this reason, an exposure management protocol is an important component of an Office Manual. All OHCWs must know the dental office’s exposure prevention policies and exposure management protocol and review them periodically. Significant exposures include percutaneous injuries with contaminated needles, burs or other sharp instruments, as well as incidents in which blood, saliva or other body fluids are splashed on to non-intact skin or the mucosa of the eyes, nose or mouth. However, percutaneous injuries pose the greatest risk of transmission of blood-borne pathogens to OHCWs.

In the event of a significant exposure, immediate first-aid measures must be instituted:

• For percutaneous injuries, allow the wound to bleed briefly and freely. Then, gently wash the wound with soap and water, and bandage as needed.
• For exposures involving the eyes, nose or mouth, flush the area with copious amounts of water.
• For exposures involving non-intact skin, wash the site with soap and water. Any kind of occupational injury must be reported to a dentist in the practice.

However, in all cases involving a significant exposure, the dentist must assess the source patient’s status and risk for blood-borne illnesses by reviewing the medical history and, if necessary, asking her / him additional questions. If the patient’s HBV, HCV or HIV status is unknown, or if the patient presents with known risk factors, then her / his co-operation should be sought to clarify such information. Every reasonable effort should be made to obtain the patient’s informed consent to be tested for HBV, HCV and HIV. This can be accomplished by referring the patient to her / his family physician for consultation, assessment of risk factors and any blood tests that are considered necessary. At the same time, the injured OHCW should be referred to her / his family physician, an infectious disease specialist or hospital emergency department for counselling, baseline blood tests and, if deemed necessary, post exposure prophylaxis. If necessary, post-exposure prophylaxis should be administered as soon as possible. For example, in the event of a high-risk exposure to HIV infection, antiretroviral drugs should be administered within hours.

All cases involving a significant exposure must be documented, including:

• name of the exposed OHCW and details regarding her / his vaccination status;
• date and time of the exposure;
• nature of the exposure, including the dental procedure being performed, the extent of the exposure and the immediate action taken;
• name of the source and details regarding her / his known or suspected status related to blood-borne pathogens;
• follow-up counselling and post-exposure management.

The instrument reprocessing area must provide for one-directional flow of instruments with clear separation of dirty and clean sides to prevent cross-contamination.  

Attention must be given to the placement of sinks in the instrument reprocessing area. In order that clean areas remain dry and free from contamination, minimize splashing from sinks, which may necessitate the installation of a physical barrier in smaller dental offices. If a physical barrier is required, it must be constructed of materials that can withstand regular cleaning and disinfection.

The instrument reprocessing area must have separate sections for:

• receiving, cleaning and decontamination;
• rinsing and drying;
• preparation and packaging;
• sterilization;
• storage.

Smooth, nonporous and seamless furnishings, surfaces and finishes are preferred. Cloth or wood furnishings and carpeting are difficult to clean, cannot be reliably disinfected and MUST NOT be used in clinical areas. Contact the regional IPAC support team at Public Health Ontario for more information.

All instruments must be sterilized by either steam under pressure (i.e. autoclaving), which is dependable and economical, or dry heat. Chemiclaves and bead sterilizers are NOT acceptable methods of sterilization.  For steam sterilization, dynamic air removal steam sterilizers (e.g. pre-vacuum and steam-flush pressure pulse sterilizers) are preferred over gravity displacement sterilizers. 

Tabletop sterilizers with recording devices are preferred. If a sterilizer does not have a recording device, the physical parameters must be checked DURING the sterilization cycle for each load and documented. If a sterilizer does have a recording device, the physical parameters must be checked at the END of the sterilization cycle for each load and documented. This is to verify that the pre-programmed cycle operated correctly, and that the required conditions for sterilization existed in the chamber.

This depends on the type of sterilizer used. Check your operator manual to confirm the type of sterilizer.

For pre-vacuum sterilizers (e.g., BRAVO, Tuttnauer and others):

• Perform an air removal test (e.g., Bowie-Dick) at the beginning of each day that the sterilizer is used.
• Place an air removal process challenge device (PCD) in the chamber of an empty sterilizer as per the manufacturer’s instructions for use.
• Record the results of this test in the sterilization log book.

For steam-flush pressure pulse sterilizers (e.g., STATIM, Midmark M11 and others), a Type 2 chemical indicator test is generally not required. Check your operator manual to confirm and follow the manufacturer's instructions.

Dental handpieces are considered semi-critical items:

• If the handpiece (including the coupler and motor component) is detachable from the air/waterlines, remove and sterilize it between every patient appointment.
• If instrument components are permanently attached to dental unit waterlines (for example, some electric handpiece motors, handles for ultrasonic devices, and attachments for saliva ejectors, high-volume suction and air / water syringes), cover these components with barriers that are changed after each patient use. Clean and disinfect contaminated or possibly contaminated items with an appropriate low-level disinfectant between every patient appointment.

Strictly follow the manufacturer’s instructions for cleaning, lubricating and sterilizing all devices.

A process challenge device (PCD) is a test used to assess the performance of the sterilization process. A PCD may be commercially manufactured or created in-house. Both are acceptable.

A PCD may be created in-house by selecting one instrument package for the load that is the most challenging to sterilize and placing a Type 5 or 6 chemical indicator and/or a BI inside. To identify this package, label it “PCD”.

The PCD is checked at the conclusion of the sterilization cycle for the load to confirm that the Type 5 or 6 chemical indicator has passed and/or the BI has passed.

Although not mandatory, tabletop sterilizers with recording devices are preferred.

All new sterilizers must have a recording feature. If a sterilizer does not have a recording device, consider replacing it in a reasonable time.

The presence or absence of a recording device:

• determines how and when you document physical cycle parameters (i.e., cycle time, temperature and pressure); and
• dictates the use of Type 5 or 6 chemical indicators when releasing a load of instruments in the absence of BI quarantine.

The quarantine of instruments pending biological indicator (BI) test results is the gold standard for sterilization.

If instruments cannot be quarantined pending BI results (due to low instrument volume or a fast-paced clinical practice environment), you may use a Type 5 or 6 chemical indicator to justify the release of instruments for use, as described above.

The minimum requirement is that one BI test is run on each sterilizer, for each day that it is used AND for each type of cycle that is used.

The minimum requirement for BI testing does not change based on the type of BI test used (e.g., 24-hours, 1-hour, 24-minutes, etc.). However, the length of quarantine may change, based on the type of BI used, and so may your recall protocol.

BI testing may ONLY clear the following loads:

1. Instruments sterilized in the cycle/load that carried the actual BI test;
2. Instruments sterilized in cycles/loads between the load carrying the BI test and the last prior load carrying a BI test that passed.

A BI test does not clear instruments sterilized in cycles/loads subsequent to the load carrying the BI test.

For example, if your practice runs a BI test in load 1 today, and subsequently runs another three loads of instruments throughout the day without BI tests (i.e., loads 2, 3, and 4):

• You may quarantine these instruments until the BI test from this load (load 1) clears (e.g., in 24-hours, 1-hour, 24-minutes, etc., depending on which type of BI test is used); OR
  • If the instruments cannot be quarantined for this time period, you may use a Type 5 or 6 CI to justify the release of instruments for use. However, these instruments should be trackable through an office recall protocol, until the results of the BI test from this load (load 1) are known.
• For loads 2, 3 and 4, which do not contain a BI test, but are run on the same day:
  • You may quarantine the instruments in these loads, until both the BI test from load 1 clears (e.g., in 24-hours, 1-hour, 24-minutes, , depending on which type of BI test is used), as well as the next BI test, which may be run later on the same day or the next day; OR
  • If the instruments cannot be quarantined for this time period, you may instead use a Type 5 or 6 CI to justify the release of instruments for use. However, these instruments should be trackable through an office recall protocol until the results of both the BI test from load 1 and the next cycle/load containing a BI are known.

Please note that implantable devices must be quarantined until the BI test results are known.

• To ensure operational qualification of a new or loaner machine that has not failed a BI test or been repaired, 3 consecutive empty chamber sterilization cycles are required. For each test, the BI and internal CI (minimum Type 5) must be placed in a PCD. If the internal CI cannot be viewed without opening the PCD, then an external CI must also be used to distinguish processed versus unprocessed PCDs. You must repeat this process for each type of sterilization cycle you will use. If the machine passes all tests, then it can be put into service.

• To ensure operational requalification of an existing machine that has failed a BI test and been repaired, and is being prepared to be put back into service, 3 consecutive full chamber sterilization cycles are required. For each test, the BI and internal CI (minimum Type 5) must be placed in a PCD. If the internal CI cannot be viewed without opening the PCD, then an external CI must also be used to distinguish processed versus unprocessed PCDs. You must repeat this process for each type of sterilization cycle you will use. If the machine passes all tests, then it can be put into service. The instrument packages from these full chamber test cycles cannot be released, until the results of all tests are known.

Please note:

• If the sterilizer has a dynamic-air-removal system (i.e., vacuum-assisted or prevacuum machines), you will also need to conduct a single successful air-detection or Type 2 (e.g., Bowie-Dick) test, prior to conducting the series of 3 BI tests.
• As part of the sterilization monitoring requirement, a record must be maintained of all test results.
• In all scenarios, check the operator manual and manufacturer’s instructions for use (MIFUs). There may be additional required or recommended steps to optimize safety and performance.

Check and record physical parameters (or mechanical indicators) for each load. This includes cycle time, temperature & pressure. 

If the sterilizer has a recording device, check and document the physical parameters at the end of the sterilization cycle for each load. 

If the sterilizer does not have a recording device, check and document the physical parameters during the sterilization mid-cycle for each load.

This verifies that the pre-programmed cycle operated correctly, and that the required conditions for sterilization existed in the chamber.

Best practice for sterilization monitoring dictates quarantining instrument loads until the results of the BI test are known.

For routine loads, if quarantine is not possible pending BI results, you must use a Type 5 or 6 CI to release instruments.

For sterilizers with a recording device, include a Type 5 or 6 CI in a PCD(commercially manufactured or made in-house) for each load that will be released. Alternatively, include a Type 5 or 6 CI in each instrument package that will be released. Visually verify, document and maintain the results of this CI before releasing instruments.

For sterilizers without a recording device, include a Type 5 or 6 CI in each instrument package that will be released. Visually verify, document and maintain the results of these CI before releasing instruments.

Please note that implantable devices must be quarantined until the BI test results are known.

No - there is no College requirement to record sterilization information directly in the patient's chart.

However, there is a requirement to have a documented recall policy and procedure in place for the recall of instruments in the event of a reprocessing failure or sterilizer malfunction. Depending on how this policy is structured, recording information in the patient's chart may assist in the recall of instruments.

For further assistance, you may contact practiceadvisory@rcdso.org or (416) 934-5614.

The College specifies the monitoring information that must be recorded, but does not require that any particular monitoring record be followed. It is ultimately the dentist's responsibility to ensure a monitoring record is maintained that meets the requirements set out in the Standard.

Dentists may create their own template for a monitoring record. Page 25 of the Standard links to a sample monitoring record, provided by Public Health Ontario (PHO). In addition, several companies and operator manuals provide monitoring record templates.

As described in the Standard, like other administrative or office records, a sterilization monitoring log book must be maintained for at least 10 years from the date of the last entry in that record.

Both formats are acceptable.

If a digital log book is maintained, the requirements outlined in the Guidelines on Electronic Records Management apply, including appropriate and routine (i.e. daily) backup of patient records and critical data.

Please confirm with your local Public Health Unit (LPHU) to determine if other requirements exist.

No - there is no College requirement to retain the printouts or “raw data” from the recording device.

However, physical parameters, including cycle time, temperature and pressure, must be verified at the conclusion of the sterilization cycle for each load and documented in a sterilization monitoring log book.

Please confirm with your local Public Health Unit (LPHU) to determine if other requirements exist.

Yes - sterilization monitoring records and log books are part the administrative or office records of a dental practice and should be transferred to the new owner of the practice during a sale/purchase.

Like other administrative or office records, the log book must be maintained for at least 10 years from the date of the last entry in that record.

Sterilization pouches or bags, as well as cassettes, must include the following information:

• date reprocessed;
• sterilizer used;
• cycle or load number; and
• operator's initials.

If the instruments are not visible (e.g., wrapped cassettes), the package contents must also be labelled.

Label this information on the pouch/bag or cassette before placing it in the sterilizer. If using a marker for labelling, use one made for this specific purpose. Write on the clear plastic surface of a bag or pouch and not the paper, to avoid compromising the package.

The following must be recorded in a sterilization log book:

Any sterilizer malfunction must be documented, as well as the appropriate action taken. In addition, preventive maintenance, servicing and repair of all reprocessing equipment must be documented.

Both Category 1 and Category 2 continuing education courses are offered through various approved sponsors in Ontario.

PHO has a set of online training modules on IPAC Core Competencies and Reprocessing in Community Health Care settings: Infection Prevention and Control (IPAC) – Online Learning | Public Health Ontario.

University faculties and community colleges, as well as many private, for-profit companies also offer IPAC courses and in-office IPAC consultations.

Yes – All dentists are strongly encouraged to undertake audits of the IPAC policies and procedures in their dental offices to ensure that patient safety standards are adhered to and best practices are implemented. These audits should assess all core components of IPAC, as well as the reprocessing of instruments.

• The College has developed a self-audit checklist tool that may be used for this purpose.
• PHO has developed two checklists that may be used for auditing the IPAC policies and procedures in dental offices.

While it is preferred to involve external individuals with expertise and certification in IPAC, internal audits by knowledgeable OHCWs with sufficient knowledge to identify and remediate deficiencies may be reasonable.

All dentists have an obligation to maintain the standards of practice of the profession and must ensure that recommended IPAC policies and procedures are carried out in the offices in which they work. In addition, all dentists have an ethical duty to maintain a safe and healthy office environment for both patients and staff, and to adhere to all rules and regulations related to the operation of a dental practice, including workplace health and safety, and environmental protection.

While IPAC is the responsibility of all OHCWs, implementation and oversight rests with the principal dentist(s), who must ensure that staff are adequately trained in IPAC policies and procedures, and that the necessary supplies and equipment are available, fully operational, up to date and routinely monitored for efficacy.

The College Standard notes that oral health care workers (OHCWs) are more likely to comply with IPAC protocols if they understand the rationale for them.

Therefore, in addition to having a certificate from a dental assisting educational program offered at a Community College or a Private Career College, it is important that all OHCWs assigned to IPAC duties receive office-specific training in IPAC as part of their orientation, and whenever new tasks, procedures or equipment are introduced. This training should be supplemented whenever necessary and reviewed at least annually by means of staff meetings, attendance at continuing education courses and through self-learning programs. All OHCWs must also receive training that includes information about their exposure risks, IPAC strategies specific to their occupational tasks, and the management of any work-related illness or injury.

It is also recommended that the College IPAC Standard, as well as key reference materials and manufacturers’ instructions for use of equipment and instruments, form part of an Office Manual. The Office Manual should include a process for recording and reporting the attendance of all OHCWs at staff meetings and continuing education courses and programs.

A chairside dental assistant may perform specified IPAC duties in the dental office, as assigned by the manager of the dental office’s IPAC program, provided they have successfully completed appropriate training in IPAC.

This training should include the IPAC Core Competencies online learning modules offered by Public Health Ontario, in addition to the completion of an IPAC course or program offered through an accredited university faculty or community college, as well as office-specific training.

However, this person should NOT be placed in charge of managing the IPAC program for the office. The lead staff in charge of managing the IPAC program should be someone who has completed comprehensive formal training (e.g. formally trained level I or II DA, RDH or RN).

Please contact your local Public Health Unit for further guidance.

Reference:
IPAC Checklist for Dental Practice-Reprocessing of Dental/Medical Equipment/Devices
Infection Prevention and Control in the Dental Office

Local anesthetic carpules which are intact may be disposed of with regular office waste. Broken carpules, ampoules and vials are to be disposed of in a designated sharps container which meets the requirements set out in the College Standard.

Sharps (e.g., needles, scalpel blades, clinical glass) must be separated and collected in a YELLOW puncture-resistant, leak-proof container that is specifically designed for their management and labelled with the universal biohazard symbol. Once the container has reached the designated capacity, it must only be released to an approved biomedical waste carrier for disposal.

Other types of containers, such as empty plastic alginate canisters and water bottles, are not designed for collecting sharps and must not be used for this purpose.

Sharps may be removed and collected in one of two areas:

• At the point of use (i.e., in the operatory, before transporting the instrument tray to the reprocessing area); or
• In the receiving zone of the reprocessing space.

To prevent percutaneous injuries, contaminated instruments must be placed in a puncture-resistant covered container or locked cassette at the point of use and then transported to the reprocessing area.

The requirement for an eyewash station is based on the Occupational Health and Safety Act.

Since there is no Canadian standard for eyewash stations, the U.S. ANSI Standard Z358.1-2014 is used as a guide. The requirements for an eyewash station may be found here. 

The ANSI standard indicates that:

• The eyewash station can be plumbed or self-contained (i.e., stand-alone).
• It can be installed on a sink in an operatory.
• If there is only one sink in the reprocessing area, the eyewash station cannot be installed on this sink. It can be installed on a dedicated hand washing sink.

In addition, a plumbed or self-contained eyewash station that meets occupational health and safety requirements must be situated within a 10-second walk (i.e. 16 to 17 metres) of the reprocessing area.

When purchasing an eyewash station, look for one that is ANSI approved.

For further information, consult the Government of Canada’s Canadian Centre for Occupational Health and Safety website.

Eyewash stations are also addressed in the College’s IPAC Standard on page 21. 

Although the College works closely with Public Health in respect of IPAC matters, the College and your local Public Health Unit have different jurisdictions.

All dentists in Ontario are licensed by the RCDSO, regardless of geographic location. The local Public Health Unit is determined by geographic location. A full list of all local Public Health Units in Ontario is available here.

The College has jurisdiction to regulate individual dentists, under the RHPA (Regulated Health Professions Act, 1991). For this reason, all dentists must ensure that the College’s Standard of Practice on IPAC is followed at their place of work. 

Local Public Health Units have jurisdiction to investigate IPAC complaints against individual dental offices, under the HPPA (Health Protection and Promotion Act, 1990). Public Health Ontario (PHO) publishes IPAC requirements, which are enforced by local Public Health Units. For the most part, these requirements overlap with the College’s Standard; however, there are some differences. The current PHO IPAC Checklists for Dental Practice can be found here. All dentists must ensure that the dental office at which they work adheres to these Public Health requirements, as well.

To learn more about the process for investigation of an IPAC complaint by Public Health, please contact your local Public Health Unit.

Dentists must have a recall protocol in place and refer to this protocol if there is an IPAC lapse.

If an IPAC lapse is identified in your office, take the following steps:

• Immediately remove suspect equipment from service and investigate possible procedural errors.
• Immediately begin the recall protocol to identify all affected instruments and possibly patients.
• Maintain clear and comprehensive records and logbook entries.
• Initiate steps towards avoiding future lapses. This includes equipment repair, staff training and communication etc. 

Note: If a BI test fails, this may or may not be classified as an IPAC lapse. Affected instruments must be quarantined until the test is repeated according to the algorithm noted in the College Standard. If subsequent BI tests pass, the instruments may be released for use and all test results recorded in the sterilization monitoring logbook. If subsequent BI tests continue to fail, this can now be classified as an IPAC lapse. These instruments may not be released for use and further investigation is required to identify any other cycles which may have been affected. In this case, as in others, the recall protocol should be closely followed, including the cascade of events outlined above.  

If an IPAC lapse is identified in your office:

• You must notify your local Public Health Unit. The Public Health Unit, with consultation from Public Health Ontario, will be able to undertake a risk assessment and advise as to whether patients should be notified.
• You may contact the College as well, in order to receive guidance and report the incident.