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APSIC dental infection prevention and control (IPC) guidelines

APSIC dental infection prevention and control (IPC) guidelines Background The Asia Pacific Society of Infection Control launched the Infection Prevention and Control Guidelines in July 2022. This document describes the guidelines and recommendations for safe practices in dental setting. It aims to highlight practical recommendations in a concise format designed to assist dental facilities at Asia Pacific region in achieving high standards in infection prevention and control practices, staff and patient safety. Method The guidelines were developed by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published international guidelines and recommendations relevant to each section. Results It recommends standard precautions as a minimal set of preventive measures to protect staff and prevent cross transmission. Surgical aseptic technique is recommended when procedures are technically complex and longer in duration. Only trained staff are eligible to conduct reprocessing of dental instruments. The design, layout of the dental facility are important factors for successful infection prevention. The facility should also have a Pandemic Pre- paredness Plan. Conclusions Dental facilities should aim for excellence in infection prevention and control practices as this is part of patient safety. The guidelines that come with a checklist help dental facilities to identify gaps for improvement to reach this goal. Keywords Infection prevention, Infection control, Dental document is to highlight IPC recommendations in a Introduction concise format designed to assist dental facilities at Asia COVID-19 pandemic had recently highlighted the of Pacific region in achieving high standards in IPC prac - transmission mechanism of SARS-CoV-2 through res- tices to minimize cross infection between the dental care piratory droplets and aerosols [1, 2]. Attention to infec- practitioner and the patient. Particularly in dental treat- tion prevention and control (IPC) practices in dental ment settings, practitioners are often exposed to contacts units is critical to stop cross-infection. The intent of this with patients, blood and bodily fluids. Additionally, the use of sharp instruments significantly increases the risk *Correspondence: of exposure to infection, and as dental treatment is a type M. L. Ling of outpatient, invasive treatment, effective controls for ling.moi.lin@singhealth.com.sg Singapore General Hospital, Outram Road, Singapore 169403, Singapore outpatient-derived infections are essential. This docu - The University of Hong Kong, Hong Kong, China ment is a summary of the APSIC Dental Infection Pre- Taipei Medical University, Taipei, Taiwan vention and Control (IPC) Guidelines developed by the National Healthcare Group Polyclinics, Singapore, Singapore University of Adelaide, Adelaide, Australia Asia Pacific Society of Infection Control (APSIC) to give Department of Health, Hong Kong, China the user an overview of its content. The full APSIC Den - Seoul National University, School of Dentistry, Seoul, South Korea tal Infection Prevention and Control (IPC) Guidelines National Dental Centre, Singapore, Singapore © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ling et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 2 of 7 available at https:// apsic- apac. org should be read and General IPC measures [3–5] used as reference to guide practice. In the dental care settings, various transmission mecha- nisms are possible—contact with body-derived sub- stances and contaminated environments, droplet Guidelines development workgroup composition transmission, and airborne transmission by aerosols, etc. APSIC convened experts in infection prevention and Effective precautions are essential since both patients and control and dentistry from Asia Pacific region to develop staff are at risk of exposure to blood-borne pathogens the APSIC Dental Infection Prevention and Control while performing health care or nursing. Patients sus- (IPC) Guidelines. The members of this workgroup are the pected of having infections transmitted by airborne route authors of this paper. should be rescheduled until the period of communicabil- ity is over. In emergency situations and procedures are unavoid- Literature review and analysis able, the patient should preferably be seen as the last For the APSIC guideline, the workgroup reviewed pre- patient of the day, with appropriate barrier precautions viously published international guidelines and recom- used and staff assisting in the dental treatment must be mendations relevant to each section and performed aware of their immune status for the relevant infectious computerized literature searches using PubMed. disease of the patient. The use of dental dam, where pos - sible, for restorative work is recommended to reduce exposure of dental practitioners and clinical support Process staff to potentially infected aerosols. When treating these The workgroup met on 2 occasions as well as discussed patients, it would also be prudent for clinical staff to wear via email correspondences to complete the development well-fitted masks or respirators with high filtration capa - of the guideline. Criteria for grading the strength of rec- bilities such as the N95 respirator. It would also be pru- ommendation and quality of evidence are described in dent to use pre-procedural mouth rinses and appropriate Table  1. The draft was then submitted to two external disinfectant for surface cleaning and disinfection at the reviewers, APSIC executive committee and national end of the appointment. infection prevention and control societies in Asia Pacific. In general, the following recommendations for routine Comments obtained were then reviewed by the work- work will include the following: group for necessary edits, following which the final copy was circulated for approval and endorsement by the APSIC executive committee and national societies from 1. Standard precautions are to be complied with by all the Asia Pacific region. dental staff. [A1I] Table 1 Categories for strength of each recommendation Categories for strength of each recommendation Category Definition A Good evidence to support a recommendation for use B Moderate evidence to support a recommendation for use C Insufficient evidence to support a recommendations for or against use D Moderate evidence to support a recommendations against use E Good evidence to support a recommendation against use Categories for quality of evidence on which recommendations are made Grade Definition I Evidence from at least one properly randomized, controlled trial II Evidence from at least one well-designed clinical trial without rand- omization, from cohort or case-controlled analytic studies, prefer- ably from more than one centre, from multiple time series, or from dramatic results in uncontrolled experiments III Evidence from opinions of respected authorities on the basis of clinical experience, descriptive studies, or reports of expert committees Ling  et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 3 of 7 2. Transmission-based precautions (airborne, droplet zones are determined by what is touched and where the and contact precautions) should be practised in addi- droplets, splash or spatter has spread. Clinical contact tion to standard precautions where appropriate. [AII] surfaces in the contaminated zone not barrier protected 3. Airborne precautions include use of a special ven- must be cleaned after each patient. tilated room with negative pressure and staff must Routine cleaning of the clinical area is necessary wear N95 or FFP2/FFP3 respirators. [BI] to maintain safe environment because dust soil and 4. Droplet precautions include staff wearing a surgical microbes on the environment surfaces can transmit mask on entering the room. [BI] infection. 5. Contact precautions include the use of disposable The environment should be clean, free from dust, dirt gloves and gown. [BI] and body fluid stains and spillages. Compliance with safe 6. Reschedule patients with pulmonary tuberculosis, care and safe working environment is the key to quality chicken pox and measles. [BII] care. The use of audit check list to conduct regular audits help identify discrepancies between standards and the actual practices among the team. Management of medical and related waste (also Asepsis and surgical management [6–10] referred to as contaminated waste) must conform to Aseptic technique aims to prevent the introduction of national and institution regulations. It is recommended micro-organisms from hands, surfaces and equipment that the dental facility develop a waste management pro- to a susceptible sterile site. Surgical aseptic technique is gram according to the national and institutional regula- demanded when procedures are technically complex, and tion and guide. longer in duration. The concept of a main critical aseptic Most dental unit waterlines contain biofilm, which field is considered and hence, sterile gloves and protec - acts as a reservoir of microbial contamination. It is rec- tive barriers (e.g. drapes) are required. A surgical hand ommended that dental unit waterline systems must be scrub is required prior to any aseptic task or procedure. regularly maintained, via water treatment and moni- Recommendations on asepsis and surgical manage- toring, and performed according to the manufacturer’s ment include: instruction. Recommendations for safe dental environment include: 1. The principles of IPC and standard aseptic technique must be applied to all dental procedures, specifically those which are technically simple and short in dura- 1. Establish policies and procedures for routine clean- tion (approximately < 20 min). [AI1] ing and disinfection of the environmental surfaces in 2. The principles of IPC and surgical aseptic technique dental healthcare settings. [AIII] must be applied to all surgical dental procedures, particularly those where there is a planned penetra- a. If surface barriers are used to protect clinical tion of the oral mucosa. [AI1] contact surfaces (e.g., switches on `dental chairs, 3. Effective hand hygiene is an essential part of aseptic computer equipment) change surface barriers technique. [A1] between patients. 4. A surgical hand scrub using an antimicrobial hand- b. Clean and disinfect clinical contact surfaces that washing solution, or an alcohol based hand rub are not barrier-protected with approved hospital (ABHR) approved for surgical hand decontamina- grade disinfectant at the start of the day and after tion, is required for surgical aseptic technique [A1] each patient. [BIII] 5. Sterile gloves must be used for surgical aseptic tech- nique [A1] 2. Select EPA-registered disinfectants or detergents 6. An aseptic field is necessary to provide a controlled with label claims for use in health care settings. [AIII] aseptic working space to help maintain the integrity 3. Follow manufacturer instructions for use of cleaners of asepsis during surgical procedures. [AI1] and EPA-registered disinfectants (e.g. amount, dilu- tion, contact time, safe use, disposal). [BIII] 4. Follow national and institutional regulation on man- Dental environment [3, 11–15] aging different types of waste. [BII] The facility is divided into two zones: clean and contami - 5. Use water that meets the CDC recommended limit nated zones, where the clean zones are where there is no for dental procedural water (i.e., ≤ 500  CFU/mL patient care activities e.g. staff room, office area, wait - of heterotrophic water bacteria) for routine dental ing and reception areas, storage supply area and steri- treatment output water. Adopt appropriate infection lized instruments and equipment; and the contaminated control procedures for dental unit waterlines. These Ling et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 4 of 7 Instruments handling and reprocessing [20–23] include flushing dental unit waterline, use of germi - The dental instrument reprocessing cycle includes the cidal product, biofilm prevention and monitoring of vital steps of cleaning and disinfection, inspection, water quality from the dental unit waterline. [AII] packaging, sterilization, documentation and before 6. Use only sterile saline or sterile water as a coolant/ they are reused on the next patient. These are assigned irrigant when performing surgical procedures. [AII] to DHCPs with training in the required reprocessing steps to ensure reprocessing results in a device that can be safely used for patient care, including the appropri- ate use of PPE necessary for safe handling of contami- Special procedures and IPC issues [16–19] nated equipment. Potential occupational exposures at the dental facility Pre-cleaning is strongly recommended before dis- may occur arising from grinding, polishing or other infection to improve the safety and effectiveness of aerosol generating procedures at laboratories, surger- instrument reprocessing. It ensures the removal of ies, etc. Standard precautions including appropriate organic remnants that the microbes are embedded in. environment/equipment hygiene would help ensure all If this organic layer is not removed properly, it can health activities are carried out in a safe and healthy shield the microorganisms and potentially compromise environment for both dental health care professionals the disinfection or sterilization process. If cleaning is (DHCPs) and patients. delayed, the soiled instruments can be kept in liquid Recommendations for special procedures include: solution which could be any proprietary product for pre-cleaning. Drying out of the uncleaned debris will 1. All impressions and appliances should be thoroughly make subsequent cleaning more difficult. Separation cleaned and rinsed of all debris before being handled of dirty and clean zones must be clearly demarcated to in the on-site laboratory or sent to an off-site labora - ensure no mixing of contaminated instruments from tory. [BII] cleaned/disinfected instruments before sterilization. 2. The dental on-site laboratory staff should wear Cleaning verification by users must be performed to appropriate PPE (mask, gloves and protective eye- assess level of cleanliness of instrument surfaces. This wear) to perform disinfection. [AII] can be done by mainly visual inspection with the aid of 3. Heat-tolerant items used in the mouth must be lighted magnifying lens if needed. Other verification cleaned and heat sterilized before being used on methods (e.g. ATP, protein residue, etc.) if deemed nec- another patient. [AII] essary can also be used. 4. Environmental surfaces should be barrier-protected Regular monitoring of the sterilization cycle is nec- or cleaned and disinfected with low-level disinfect- essary to ensure the sterility of reprocessed instru- ants [AII] ments. Where there is a sterilization failure, a product 5. Appliances and prosthesis delivered to the patient recall must be activated and the use of the sterilizer should be free of contamination. New and old den- stopped immediately. The process of sterilization must tures should be disinfected and rinsed by treated be reviewed to rule out the possibility of operator error. water (tap water that is safe for drinking as stipulated If there is any procedural error/failure identified, this by national regulation). [AII] should be rectified and subsequently retest the steri - 6. In radiography room, when the surface is visibly con- lizer, performing the physical, biological and chemical taminated with blood or saliva, intermediate level monitoring. disinfectant should be used. [AII] Recommendations on instrument handling and 7. Radiography equipment should be cleaned and dis- reprocessing include: infected with low level disinfectant after each patient use or should be protected with surface barriers. [BII] 1. Proper cleaning, disinfection and sterilisation pro- 8. In heavy aerosol environment, high volume evacua- cesses must be clearly stated in all dental clinics and tion must be used as routine practices, and prevent- preferably be carried out by trained dental healthcare able by routine practices [BII] professionals. [BII] 9. Critical OPD surgery should have pre-procedural 2. Proper sterilisation of dental handpieces and all mouth rinses for patients to decrease the number of dental instruments is important and should follow microorganisms during invasive dental procedures. the manufacturer instructions. It is important that [AII] proper sterilisation is performed to prevent transmis- sion of microorganisms. [AII] Ling  et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 5 of 7 Incident and outbreak management [24, 25] 2. Develop and maintain regularly updated immuniza- Exposure to blood or saliva by percutaneous injury with tion/health records for dental staff. [BI] sharp injury is the greatest risk for acquiring a blood- 3. Provide job- or task-specific infection prevention borne pathogen in the dental health-care setting. The education and training to all DHCPs. [BI] dental facility should have a post-exposure management 4. Provide training during orientation and at regular protocol where staff is immediately evaluated to assess intervals (e.g., annually). [BI] the potential to transmit an infectious disease. An out- 5. Maintain training records according to state and break, if any, will need to be investigated and risk assess- national requirements. (IB) ment done to evaluate possible environmental exposures. Recommendations on managing incidents and out- breaks include: Pandemic preparedness [11] Following the 2009 influenza H1N1 and the 2020/21 1. There should be a process of notification of supervi - COVID-19 pandemics, it is clear that dental care services sors, senior management and IPC. [AIII] and clinics should have a pandemic preparedness plan. 2. A procedure should be established for the recall of Such plans shall be reviewed periodically with reference improperly reprocessed medical equipment/devices. to the most updated scientific evidence and the local [AIII] health authority. Patients suspected with a pandemic associated infec- tion should be isolated in separate room as far as pos- sible. Consider postponing elective procedures and Education and training [26, 27] non-urgent patient visits when client reports signs and Infection prevention education and training with ongo- symptoms of the pandemic infection and positive history ing program for DHCPs are critical for ensuring that of epidemiological clues (acronym TOCC), i.e. infection prevention policies and procedures are under- stood and followed. The supervisor needs to ensure: • Travel to areas with known epidemic of potential concern (EPC) within the known or suspected incu- • IPC education and training, such as hand hygiene, bation period use of PPE, appropriate to their position and respon- • Possible Occupational exposure to pathogens of sibilities is provided upon hire, at least annually, and potential concern (O) whenever new equipment or processes are intro- • Unprotected Contact with those with the EPC within duced. the known or suspected incubation period • Education on the basic principles and practices for • Being part of a rapidly spreading Cluster of patients preventing the spread of infections should be pro- with the infection of unknown cause, including expo- vided to all DHCPs. sure to household members with the EPC. • Training should include both DHCP safety (e.g., OSHA blood-borne pathogens training) and patient Recommendations on pandemic preparedness include: safety (e.g. dental instrument sterilization and disin- fection training course) 1. Dental care services clinics should have a pandemic • Regular refresher training is also appropriate to preparedness plan with reference to the local health ensure the necessary infection control measures are authority. [BII] being complied with and understood 2. Early identification through client triage process in • Regular continuing education is required and be sup- pandemic situations is key to prevent spread of infec- ported, as well as encouraged tious disease in clinic settings. [AII] • There are regular documented internal audits to 3. Consider if elective procedures and non-urgent assess the competency of staff involved in IPC proce - patient visits be postponed when patient reports dures signs and symptoms of the pandemic infection and • IPC policies are reviewed by all staff members and positive TOCC history. [BII] updated at least annually. 4. Avoid AGP as far as possible. If unavoidable, AGPs should be carried out in negative pressured rooms. Recommendations on education and training include: [BII] 5. Use fourhanded dentistry, high evacuation suction 1. There is a written policy regarding immunizing and dental dams to minimize droplet spatter and aer- DHCP, with immunization program. [CI] osols. [AII] Ling et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 6 of 7 Endorsed by 6. DHCP should wear appropriate PPE for stand- ard precautions and transmission base precautions according to pandemic guideline recommendations. 1. Hong Kong Infection Control Nurses Association [BII] (HKICNA), Hong Kong 7. Practices should ensure physical distancing. Good 2. Infection Control Association of Singapore (ICAS), hand and respiratory hygiene measures are followed Singapore at all times throughout the practice. [BII] 3. Japanese Society for Infection Prevention and Con- trol (JSIPC), Japan 4. Korean Society of Health-associated Infection Control (KOSHIC), South Korea 5. National Nosocomial Infection Group of Thailand, Design specifications [28, 29] Thailand The design, layout of dental surgery and treatment areas 6. Nursing Association for Prevention & Control of are important factors for successful infection preven- Infection, Thailand (ThaiNAPCI) tion. Work areas should be well lit and ventilated with 7. Philippine Hospital infection Control Society, sufficient uncluttered and easily cleaned bench space to (PHICS), Philippines contain dental equipment. There must be a defined area 8. Infection Control Society of Taiwan (ICST) for clean and contaminated zones in the dental opera- 9. Malaysian Society of Infection Control and Infec- tory and instrument reprocessing rooms. All dental tious Disease (MyICID), Malaysia staff must understand the purpose of and requirements 10. Indonesian Society of Infection Control (INASIC), within each zone, and adhere to the protocols. Indonesia 1. There should be clearly defined clean and contami - nated zones. [AII] Acknowledgements 2. It is highly recommended that the operatory be in We acknowledge support through an educational grant from 3M Asia Pacific. APSIC acknowledges the help of Emeritus Professor Laurence J. Walsh of the single room [BII] University of Queensland School of Dentistry, Australia; and Dr. Young Sun 3. Alcohol-based hand rub (ABHR) dispensers should Kwon, Goodface Dental Group, International Relations Counsel of Korean be installed at every operatory at the point of care to Academy of Infection Control in Dentistry (KAICD) for reviewing the docu- ment and giving their valuable comments and feedback. These guidelines facilitate easy access to hand hygiene. [AII] were prepared and approved by the Asia Pacific Society of Infection Control 4. The reprocessing area must be divided into distinct (APSIC) and do not necessarily reflect the opinions of Antimicrobial Resistance areas for: and Infection Control or its Editors. Author contributions • Receiving, cleaning and decontamination All authors (MLL, PC, JC, LL, SL, PP, YS and CS) are involved in the development • Preparation and packaging of the APSIC Dental Infection Prevention and Control (IPC) Guidelines. MLL was responsible for the initial draft of this manuscript; the other authors gave • Sterilisation and input and comments; and MLL revised the manuscript according to inputs • Storage. [AII] received. All authors read and approved the final manuscript. Funding An educational grant was received from 3 M Asia Pacific to fund the develop - ment and translation cost incurred during the development of the APSIC Conclusion Dental Infection Prevention and Control (IPC) Guidelines. We recommend all dental facilities to aim for excel- Availability of data and materials lence in IPC practices. COVID-19 pandemic had expe- Yes; the APSIC Dental Infection Prevention and Control (IPC) Guidelines is dited rapid changes in many dental practices globally available at the APSIC website (aspic-apac.org). but these changes should be long-lasting with regular reviews for strategic revisions towards achieving staff Declarations and patient safety. A checklist for self-assessment is Ethics approval and consent to participate included in the guidelines to help in identifying gaps Not applicable. for improvement. The APSIC guideline not only gives Consent for publication timely guidance on safer practices at dental facili- APSIC gives consent for this manuscript to be published. ties during the COVID-19 pandemic but its continual implementation will certainly assist dental facilities to Competing interests The authors declare that they have no competing interests. ensure appropriate safe practices are in place to miti- gate healthcare associated infections. Ling  et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 7 of 7 Received: 15 September 2022 Accepted: 9 May 2023infec tionc ontrol/ summa ry- infec tion- preve ntion- pract ices/ index. html. Accessed 24 Mar 2021. 22. The basic protocol—IC guidelines for the dental services, Department of Health, HKSAR Government, Infection Control Standing Committee Dental Service; 2019. 23. The APSIC guidelines for disinfection and sterilisation of instruments in References healthcare facilities. 1. Froum SH, Froum SJ. Incidence of COVID-19 virus transmission in three 24. Legionella (Legionnaires’ disease and Pontiac Fever). US CDC things dental offices: a 6-month retrospective study. Int J Periodontics Restor to consider: outbreak investigations. https:// www. cdc. gov/ legio nella/ Dent. 2020;40:853–9. health- depts/ epi- resou rces/ outbr eak- inves tigat ions. html. Accessed 19 2. Silvestre FJ, Martinez-Herrera M, Márquez-Arrico CF, Silvestre-Rangil Mar 2021. J. COVID-19, A new challenge in the dental practice. J Clin Exp Dent. 25. Guidance for dental settings. Interim infection prevention and control 2021;13(7):e709–16. https:// doi. org/ 10. 4317/ jced. 57362. guidance for dental settings during the coronavirus disease 2-19 (COVID- 3. Centers for Disease Control and Prevention. Summary of infection 19) pandemic. https:// www. cdc. gov/ coron avirus/ 2019- ncov/ hcp/ dental- prevention practices in dental settings: basic expectations for safe care. setti ngs. html# secti on-2. Accessed 19 Mar 2021. Atlanta: Centers for Disease Control and Prevention, US Department of 26. Health-care personnel: recommendations of the advisory committee on Health and Human Services; 2016. immunization practices (ACIP). http:// www. cdc. gov/ mmwr/ pdf/ rr/ rr6007. 4. Guidelines for Infection Control in Dental Health-Care Settings—2003. pdf. https:// www. cdc. gov/ mmwr/ previ ew/ mmwrh tml/ rr521 7a1. htm. 27. Gould D, Chamberlain A. The use of a ward-based educational teaching Accessed 24 Mar 2021. package to enhance nurses’ compliance with infection control proce- 5. Guideline for isolation precautions: preventing transmission of infectious dures. J Clin Nurs. 1997;6(1):55–67. agents in healthcare settings. www. cdc. gov/ hicpac/ pdf/ isola tion/ Isola 28. Interim infection prevention and control guidance for dental settings tion2 007. pdf. Accessed 24 Mar 2021. during the coronavirus disease 2019 (COVID-19) pandemic. Updated 4 6. Australian guidelines for the prevention and control of infection in Dec 2020. https:// www. cdc. gov/ coron avirus/ 2019- ncov/ hcp/ dental- setti Healthcare, Canberra: National Health and Medical Research Council ngs. html# secti on-1. Accessed 24 Mar 2021. (2019). Aseptic Technique; Section 3.1.6. p. 91. https:// www. nhmrc. gov. 29. 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At BMC, research is always in progress. 21. Summary of infection prevention practices in dental settings: basic Learn more biomedcentral.com/submissions expectations for safe care; 2016. https:// www. cdc. gov/ oralh ealth/ http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Antimicrobial Resistance and Infection Control Springer Journals

APSIC dental infection prevention and control (IPC) guidelines

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Abstract

Background The Asia Pacific Society of Infection Control launched the Infection Prevention and Control Guidelines in July 2022. This document describes the guidelines and recommendations for safe practices in dental setting. It aims to highlight practical recommendations in a concise format designed to assist dental facilities at Asia Pacific region in achieving high standards in infection prevention and control practices, staff and patient safety. Method The guidelines were developed by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published international guidelines and recommendations relevant to each section. Results It recommends standard precautions as a minimal set of preventive measures to protect staff and prevent cross transmission. Surgical aseptic technique is recommended when procedures are technically complex and longer in duration. Only trained staff are eligible to conduct reprocessing of dental instruments. The design, layout of the dental facility are important factors for successful infection prevention. The facility should also have a Pandemic Pre- paredness Plan. Conclusions Dental facilities should aim for excellence in infection prevention and control practices as this is part of patient safety. The guidelines that come with a checklist help dental facilities to identify gaps for improvement to reach this goal. Keywords Infection prevention, Infection control, Dental document is to highlight IPC recommendations in a Introduction concise format designed to assist dental facilities at Asia COVID-19 pandemic had recently highlighted the of Pacific region in achieving high standards in IPC prac - transmission mechanism of SARS-CoV-2 through res- tices to minimize cross infection between the dental care piratory droplets and aerosols [1, 2]. Attention to infec- practitioner and the patient. Particularly in dental treat- tion prevention and control (IPC) practices in dental ment settings, practitioners are often exposed to contacts units is critical to stop cross-infection. The intent of this with patients, blood and bodily fluids. Additionally, the use of sharp instruments significantly increases the risk *Correspondence: of exposure to infection, and as dental treatment is a type M. L. Ling of outpatient, invasive treatment, effective controls for ling.moi.lin@singhealth.com.sg Singapore General Hospital, Outram Road, Singapore 169403, Singapore outpatient-derived infections are essential. This docu - The University of Hong Kong, Hong Kong, China ment is a summary of the APSIC Dental Infection Pre- Taipei Medical University, Taipei, Taiwan vention and Control (IPC) Guidelines developed by the National Healthcare Group Polyclinics, Singapore, Singapore University of Adelaide, Adelaide, Australia Asia Pacific Society of Infection Control (APSIC) to give Department of Health, Hong Kong, China the user an overview of its content. The full APSIC Den - Seoul National University, School of Dentistry, Seoul, South Korea tal Infection Prevention and Control (IPC) Guidelines National Dental Centre, Singapore, Singapore © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ling et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 2 of 7 available at https:// apsic- apac. org should be read and General IPC measures [3–5] used as reference to guide practice. In the dental care settings, various transmission mecha- nisms are possible—contact with body-derived sub- stances and contaminated environments, droplet Guidelines development workgroup composition transmission, and airborne transmission by aerosols, etc. APSIC convened experts in infection prevention and Effective precautions are essential since both patients and control and dentistry from Asia Pacific region to develop staff are at risk of exposure to blood-borne pathogens the APSIC Dental Infection Prevention and Control while performing health care or nursing. Patients sus- (IPC) Guidelines. The members of this workgroup are the pected of having infections transmitted by airborne route authors of this paper. should be rescheduled until the period of communicabil- ity is over. In emergency situations and procedures are unavoid- Literature review and analysis able, the patient should preferably be seen as the last For the APSIC guideline, the workgroup reviewed pre- patient of the day, with appropriate barrier precautions viously published international guidelines and recom- used and staff assisting in the dental treatment must be mendations relevant to each section and performed aware of their immune status for the relevant infectious computerized literature searches using PubMed. disease of the patient. The use of dental dam, where pos - sible, for restorative work is recommended to reduce exposure of dental practitioners and clinical support Process staff to potentially infected aerosols. When treating these The workgroup met on 2 occasions as well as discussed patients, it would also be prudent for clinical staff to wear via email correspondences to complete the development well-fitted masks or respirators with high filtration capa - of the guideline. Criteria for grading the strength of rec- bilities such as the N95 respirator. It would also be pru- ommendation and quality of evidence are described in dent to use pre-procedural mouth rinses and appropriate Table  1. The draft was then submitted to two external disinfectant for surface cleaning and disinfection at the reviewers, APSIC executive committee and national end of the appointment. infection prevention and control societies in Asia Pacific. In general, the following recommendations for routine Comments obtained were then reviewed by the work- work will include the following: group for necessary edits, following which the final copy was circulated for approval and endorsement by the APSIC executive committee and national societies from 1. Standard precautions are to be complied with by all the Asia Pacific region. dental staff. [A1I] Table 1 Categories for strength of each recommendation Categories for strength of each recommendation Category Definition A Good evidence to support a recommendation for use B Moderate evidence to support a recommendation for use C Insufficient evidence to support a recommendations for or against use D Moderate evidence to support a recommendations against use E Good evidence to support a recommendation against use Categories for quality of evidence on which recommendations are made Grade Definition I Evidence from at least one properly randomized, controlled trial II Evidence from at least one well-designed clinical trial without rand- omization, from cohort or case-controlled analytic studies, prefer- ably from more than one centre, from multiple time series, or from dramatic results in uncontrolled experiments III Evidence from opinions of respected authorities on the basis of clinical experience, descriptive studies, or reports of expert committees Ling  et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 3 of 7 2. Transmission-based precautions (airborne, droplet zones are determined by what is touched and where the and contact precautions) should be practised in addi- droplets, splash or spatter has spread. Clinical contact tion to standard precautions where appropriate. [AII] surfaces in the contaminated zone not barrier protected 3. Airborne precautions include use of a special ven- must be cleaned after each patient. tilated room with negative pressure and staff must Routine cleaning of the clinical area is necessary wear N95 or FFP2/FFP3 respirators. [BI] to maintain safe environment because dust soil and 4. Droplet precautions include staff wearing a surgical microbes on the environment surfaces can transmit mask on entering the room. [BI] infection. 5. Contact precautions include the use of disposable The environment should be clean, free from dust, dirt gloves and gown. [BI] and body fluid stains and spillages. Compliance with safe 6. Reschedule patients with pulmonary tuberculosis, care and safe working environment is the key to quality chicken pox and measles. [BII] care. The use of audit check list to conduct regular audits help identify discrepancies between standards and the actual practices among the team. Management of medical and related waste (also Asepsis and surgical management [6–10] referred to as contaminated waste) must conform to Aseptic technique aims to prevent the introduction of national and institution regulations. It is recommended micro-organisms from hands, surfaces and equipment that the dental facility develop a waste management pro- to a susceptible sterile site. Surgical aseptic technique is gram according to the national and institutional regula- demanded when procedures are technically complex, and tion and guide. longer in duration. The concept of a main critical aseptic Most dental unit waterlines contain biofilm, which field is considered and hence, sterile gloves and protec - acts as a reservoir of microbial contamination. It is rec- tive barriers (e.g. drapes) are required. A surgical hand ommended that dental unit waterline systems must be scrub is required prior to any aseptic task or procedure. regularly maintained, via water treatment and moni- Recommendations on asepsis and surgical manage- toring, and performed according to the manufacturer’s ment include: instruction. Recommendations for safe dental environment include: 1. The principles of IPC and standard aseptic technique must be applied to all dental procedures, specifically those which are technically simple and short in dura- 1. Establish policies and procedures for routine clean- tion (approximately < 20 min). [AI1] ing and disinfection of the environmental surfaces in 2. The principles of IPC and surgical aseptic technique dental healthcare settings. [AIII] must be applied to all surgical dental procedures, particularly those where there is a planned penetra- a. If surface barriers are used to protect clinical tion of the oral mucosa. [AI1] contact surfaces (e.g., switches on `dental chairs, 3. Effective hand hygiene is an essential part of aseptic computer equipment) change surface barriers technique. [A1] between patients. 4. A surgical hand scrub using an antimicrobial hand- b. Clean and disinfect clinical contact surfaces that washing solution, or an alcohol based hand rub are not barrier-protected with approved hospital (ABHR) approved for surgical hand decontamina- grade disinfectant at the start of the day and after tion, is required for surgical aseptic technique [A1] each patient. [BIII] 5. Sterile gloves must be used for surgical aseptic tech- nique [A1] 2. Select EPA-registered disinfectants or detergents 6. An aseptic field is necessary to provide a controlled with label claims for use in health care settings. [AIII] aseptic working space to help maintain the integrity 3. Follow manufacturer instructions for use of cleaners of asepsis during surgical procedures. [AI1] and EPA-registered disinfectants (e.g. amount, dilu- tion, contact time, safe use, disposal). [BIII] 4. Follow national and institutional regulation on man- Dental environment [3, 11–15] aging different types of waste. [BII] The facility is divided into two zones: clean and contami - 5. Use water that meets the CDC recommended limit nated zones, where the clean zones are where there is no for dental procedural water (i.e., ≤ 500  CFU/mL patient care activities e.g. staff room, office area, wait - of heterotrophic water bacteria) for routine dental ing and reception areas, storage supply area and steri- treatment output water. Adopt appropriate infection lized instruments and equipment; and the contaminated control procedures for dental unit waterlines. These Ling et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 4 of 7 Instruments handling and reprocessing [20–23] include flushing dental unit waterline, use of germi - The dental instrument reprocessing cycle includes the cidal product, biofilm prevention and monitoring of vital steps of cleaning and disinfection, inspection, water quality from the dental unit waterline. [AII] packaging, sterilization, documentation and before 6. Use only sterile saline or sterile water as a coolant/ they are reused on the next patient. These are assigned irrigant when performing surgical procedures. [AII] to DHCPs with training in the required reprocessing steps to ensure reprocessing results in a device that can be safely used for patient care, including the appropri- ate use of PPE necessary for safe handling of contami- Special procedures and IPC issues [16–19] nated equipment. Potential occupational exposures at the dental facility Pre-cleaning is strongly recommended before dis- may occur arising from grinding, polishing or other infection to improve the safety and effectiveness of aerosol generating procedures at laboratories, surger- instrument reprocessing. It ensures the removal of ies, etc. Standard precautions including appropriate organic remnants that the microbes are embedded in. environment/equipment hygiene would help ensure all If this organic layer is not removed properly, it can health activities are carried out in a safe and healthy shield the microorganisms and potentially compromise environment for both dental health care professionals the disinfection or sterilization process. If cleaning is (DHCPs) and patients. delayed, the soiled instruments can be kept in liquid Recommendations for special procedures include: solution which could be any proprietary product for pre-cleaning. Drying out of the uncleaned debris will 1. All impressions and appliances should be thoroughly make subsequent cleaning more difficult. Separation cleaned and rinsed of all debris before being handled of dirty and clean zones must be clearly demarcated to in the on-site laboratory or sent to an off-site labora - ensure no mixing of contaminated instruments from tory. [BII] cleaned/disinfected instruments before sterilization. 2. The dental on-site laboratory staff should wear Cleaning verification by users must be performed to appropriate PPE (mask, gloves and protective eye- assess level of cleanliness of instrument surfaces. This wear) to perform disinfection. [AII] can be done by mainly visual inspection with the aid of 3. Heat-tolerant items used in the mouth must be lighted magnifying lens if needed. Other verification cleaned and heat sterilized before being used on methods (e.g. ATP, protein residue, etc.) if deemed nec- another patient. [AII] essary can also be used. 4. Environmental surfaces should be barrier-protected Regular monitoring of the sterilization cycle is nec- or cleaned and disinfected with low-level disinfect- essary to ensure the sterility of reprocessed instru- ants [AII] ments. Where there is a sterilization failure, a product 5. Appliances and prosthesis delivered to the patient recall must be activated and the use of the sterilizer should be free of contamination. New and old den- stopped immediately. The process of sterilization must tures should be disinfected and rinsed by treated be reviewed to rule out the possibility of operator error. water (tap water that is safe for drinking as stipulated If there is any procedural error/failure identified, this by national regulation). [AII] should be rectified and subsequently retest the steri - 6. In radiography room, when the surface is visibly con- lizer, performing the physical, biological and chemical taminated with blood or saliva, intermediate level monitoring. disinfectant should be used. [AII] Recommendations on instrument handling and 7. Radiography equipment should be cleaned and dis- reprocessing include: infected with low level disinfectant after each patient use or should be protected with surface barriers. [BII] 1. Proper cleaning, disinfection and sterilisation pro- 8. In heavy aerosol environment, high volume evacua- cesses must be clearly stated in all dental clinics and tion must be used as routine practices, and prevent- preferably be carried out by trained dental healthcare able by routine practices [BII] professionals. [BII] 9. Critical OPD surgery should have pre-procedural 2. Proper sterilisation of dental handpieces and all mouth rinses for patients to decrease the number of dental instruments is important and should follow microorganisms during invasive dental procedures. the manufacturer instructions. It is important that [AII] proper sterilisation is performed to prevent transmis- sion of microorganisms. [AII] Ling  et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 5 of 7 Incident and outbreak management [24, 25] 2. Develop and maintain regularly updated immuniza- Exposure to blood or saliva by percutaneous injury with tion/health records for dental staff. [BI] sharp injury is the greatest risk for acquiring a blood- 3. Provide job- or task-specific infection prevention borne pathogen in the dental health-care setting. The education and training to all DHCPs. [BI] dental facility should have a post-exposure management 4. Provide training during orientation and at regular protocol where staff is immediately evaluated to assess intervals (e.g., annually). [BI] the potential to transmit an infectious disease. An out- 5. Maintain training records according to state and break, if any, will need to be investigated and risk assess- national requirements. (IB) ment done to evaluate possible environmental exposures. Recommendations on managing incidents and out- breaks include: Pandemic preparedness [11] Following the 2009 influenza H1N1 and the 2020/21 1. There should be a process of notification of supervi - COVID-19 pandemics, it is clear that dental care services sors, senior management and IPC. [AIII] and clinics should have a pandemic preparedness plan. 2. A procedure should be established for the recall of Such plans shall be reviewed periodically with reference improperly reprocessed medical equipment/devices. to the most updated scientific evidence and the local [AIII] health authority. Patients suspected with a pandemic associated infec- tion should be isolated in separate room as far as pos- sible. Consider postponing elective procedures and Education and training [26, 27] non-urgent patient visits when client reports signs and Infection prevention education and training with ongo- symptoms of the pandemic infection and positive history ing program for DHCPs are critical for ensuring that of epidemiological clues (acronym TOCC), i.e. infection prevention policies and procedures are under- stood and followed. The supervisor needs to ensure: • Travel to areas with known epidemic of potential concern (EPC) within the known or suspected incu- • IPC education and training, such as hand hygiene, bation period use of PPE, appropriate to their position and respon- • Possible Occupational exposure to pathogens of sibilities is provided upon hire, at least annually, and potential concern (O) whenever new equipment or processes are intro- • Unprotected Contact with those with the EPC within duced. the known or suspected incubation period • Education on the basic principles and practices for • Being part of a rapidly spreading Cluster of patients preventing the spread of infections should be pro- with the infection of unknown cause, including expo- vided to all DHCPs. sure to household members with the EPC. • Training should include both DHCP safety (e.g., OSHA blood-borne pathogens training) and patient Recommendations on pandemic preparedness include: safety (e.g. dental instrument sterilization and disin- fection training course) 1. Dental care services clinics should have a pandemic • Regular refresher training is also appropriate to preparedness plan with reference to the local health ensure the necessary infection control measures are authority. [BII] being complied with and understood 2. Early identification through client triage process in • Regular continuing education is required and be sup- pandemic situations is key to prevent spread of infec- ported, as well as encouraged tious disease in clinic settings. [AII] • There are regular documented internal audits to 3. Consider if elective procedures and non-urgent assess the competency of staff involved in IPC proce - patient visits be postponed when patient reports dures signs and symptoms of the pandemic infection and • IPC policies are reviewed by all staff members and positive TOCC history. [BII] updated at least annually. 4. Avoid AGP as far as possible. If unavoidable, AGPs should be carried out in negative pressured rooms. Recommendations on education and training include: [BII] 5. Use fourhanded dentistry, high evacuation suction 1. There is a written policy regarding immunizing and dental dams to minimize droplet spatter and aer- DHCP, with immunization program. [CI] osols. [AII] Ling et al. Antimicrobial Resistance & Infection Control (2023) 12:53 Page 6 of 7 Endorsed by 6. DHCP should wear appropriate PPE for stand- ard precautions and transmission base precautions according to pandemic guideline recommendations. 1. Hong Kong Infection Control Nurses Association [BII] (HKICNA), Hong Kong 7. Practices should ensure physical distancing. Good 2. Infection Control Association of Singapore (ICAS), hand and respiratory hygiene measures are followed Singapore at all times throughout the practice. [BII] 3. Japanese Society for Infection Prevention and Con- trol (JSIPC), Japan 4. Korean Society of Health-associated Infection Control (KOSHIC), South Korea 5. National Nosocomial Infection Group of Thailand, Design specifications [28, 29] Thailand The design, layout of dental surgery and treatment areas 6. Nursing Association for Prevention & Control of are important factors for successful infection preven- Infection, Thailand (ThaiNAPCI) tion. Work areas should be well lit and ventilated with 7. Philippine Hospital infection Control Society, sufficient uncluttered and easily cleaned bench space to (PHICS), Philippines contain dental equipment. There must be a defined area 8. Infection Control Society of Taiwan (ICST) for clean and contaminated zones in the dental opera- 9. Malaysian Society of Infection Control and Infec- tory and instrument reprocessing rooms. All dental tious Disease (MyICID), Malaysia staff must understand the purpose of and requirements 10. Indonesian Society of Infection Control (INASIC), within each zone, and adhere to the protocols. Indonesia 1. There should be clearly defined clean and contami - nated zones. [AII] Acknowledgements 2. It is highly recommended that the operatory be in We acknowledge support through an educational grant from 3M Asia Pacific. APSIC acknowledges the help of Emeritus Professor Laurence J. Walsh of the single room [BII] University of Queensland School of Dentistry, Australia; and Dr. Young Sun 3. Alcohol-based hand rub (ABHR) dispensers should Kwon, Goodface Dental Group, International Relations Counsel of Korean be installed at every operatory at the point of care to Academy of Infection Control in Dentistry (KAICD) for reviewing the docu- ment and giving their valuable comments and feedback. These guidelines facilitate easy access to hand hygiene. [AII] were prepared and approved by the Asia Pacific Society of Infection Control 4. The reprocessing area must be divided into distinct (APSIC) and do not necessarily reflect the opinions of Antimicrobial Resistance areas for: and Infection Control or its Editors. Author contributions • Receiving, cleaning and decontamination All authors (MLL, PC, JC, LL, SL, PP, YS and CS) are involved in the development • Preparation and packaging of the APSIC Dental Infection Prevention and Control (IPC) Guidelines. MLL was responsible for the initial draft of this manuscript; the other authors gave • Sterilisation and input and comments; and MLL revised the manuscript according to inputs • Storage. [AII] received. All authors read and approved the final manuscript. Funding An educational grant was received from 3 M Asia Pacific to fund the develop - ment and translation cost incurred during the development of the APSIC Conclusion Dental Infection Prevention and Control (IPC) Guidelines. We recommend all dental facilities to aim for excel- Availability of data and materials lence in IPC practices. COVID-19 pandemic had expe- Yes; the APSIC Dental Infection Prevention and Control (IPC) Guidelines is dited rapid changes in many dental practices globally available at the APSIC website (aspic-apac.org). but these changes should be long-lasting with regular reviews for strategic revisions towards achieving staff Declarations and patient safety. A checklist for self-assessment is Ethics approval and consent to participate included in the guidelines to help in identifying gaps Not applicable. for improvement. The APSIC guideline not only gives Consent for publication timely guidance on safer practices at dental facili- APSIC gives consent for this manuscript to be published. ties during the COVID-19 pandemic but its continual implementation will certainly assist dental facilities to Competing interests The authors declare that they have no competing interests. ensure appropriate safe practices are in place to miti- gate healthcare associated infections. Ling  et al. 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Journal

Antimicrobial Resistance and Infection Control – Springer Journals

Published: May 30, 2023

Keywords: Infection prevention; Infection control; Dental

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