Infection Control: Focusing on the 'pathways'

Feb. 1, 2001
Organizing the procedures around the five pathways of spread may assist in the periodic review of the dental office's program,

When you think of the office's overall infection control program, it can appear overwhelming. However, if you consider the program in sections, it may become much more manageable, as well as easier to review and update. One approach to looking at the various sections is to consider the pathways by which microbes are spread in the office:

  • Patient to dental team
  • Dental team to patient
  • Patient to patient
  • Office to community
  • Community to office

In some instances, an infection control procedure can control more than one pathway of microbial spread. Nevertheless, this grouping of procedures by pathway still may be beneficial when organizing or reviewing the office's program. Categorizing the procedures also may provide a better appreciation for why certain procedures are performed, and this is especially important when training new office staff.

Patient to dental team - The patient (or more specifically, the patient's mouth) is the most important source of microbes in the office. The general approach to managing this pathway is to:

  • Reduce the number of microbes present in patients' mouths
  • Reduce the escape of microbes from patients' mouths
  • Prevent contact with those that do escape.

Infection control procedures involved with interrupting the spread of microbes from the patient to a member of the dental team include:

  • Handwashing
  • The use of barriers (patient care and utility gloves, masks, faceshields, protective eyeglasses, protective clothing)
  • The use of high-volume evacuation and the rubber dam
  • Handling sharps carefully
  • Pre-procedure mouth rinsing
  • Mechanical cleaning of instruments (instead of hand scrubbing)
  • Using instrument cassettes (to reduce direct handling of contaminated sharps)

Dental team to patient - This pathway is not prominent, but must certainly be addressed. The general approach for interrupting this pathway is to prevent direct contact between the patients and body fluid or skin microbes of the dental team member. The main preventive procedures in this area are handwashing and the use of gloves, masks, and faceshields. Secondary procedures include sterilization of instruments as well as surface cleaning and disinfection.

Patient to patient - This pathway is completed when a patient contacts any item or surface contaminated with microbes from a previous patient. This, too, is not prominent, but the prevention procedures involve:

  • Handwashing
  • Instrument cleaning, packaging, and sterilization
  • Use of patient care gloves and mask (and changing them between patients)
  • Surface cleaning and disinfection
  • Use of surface covers (and changing them between patients)
  • Use of disposable prophy angles, air/water syringe tips, HVE tips, and other single-use items
  • Proper disposal of contaminated single-use items
  • Use of an aseptic retrieval process to prevent contamination of supply items
  • Changing protective clothing when needed
  • Cleaning eyeglasses between patients

Office to community - This pathway involves the escape of microbes from the office to persons outside the office. The overall prevention goal centers on containment. Interrupting this pathway of spread involves:

  • Handwashing
  • Proper containment and disposal of regulated waste
  • Not wearing contaminated clothing/barriers out of the office
  • Disinfection of items sent to dental laboratories
  • Disinfection or proper labeling of contaminated items sent out for repair
  • Proper packaging of specimens sent to laboratories
  • Cleaning and disinfection of extracted teeth returned to patients

Community to office - Air, dust, water, people, supplies, etc. intermittently enter most all buildings to produce naturally occurring pathways for microbe movement. However, even though these pathways are very common, the public may hold a facility such as a dental office to a higher standard, expecting a cleaner environment. Preventing the entrance of microbes into the office from the outside is impossible. However, the extent of contamination that occurs by this pathway can be reduced. Useful procedures include:

  • Routine housekeeping (vacuuming the waiting room carpet, dusting, and wet mopping hard-surface floors)
  • Routine changing of room air and furnace filters
  • Cleaning and disinfecting items received from dental laboratories before they are placed in a patient's mouth
  • Cleaning and sterilizing all new instruments before they are first used on patients
  • Cleaning new equipment items before use
  • Keeping patient care items and supplies covered (protected from dust) when not in use
  • Maintaining good quality dental treatment water that may involve proper maintenance of dental unit waterlines.

In summary, the office's infection control program can be thought of as a collection of procedures designed to interfere with pathways of microbe spread. Organizing the procedures around the five pathways of spread may assist in the periodic review of the dental office's program, as well as during training on mechanisms of disease prevention in the office.

Chris Miller, PhD, is professor of oral microbiology and executive associate dean at the Indiana University School of Dentistry.