Operatory Protocol

It will be discussed with respect to

•  The operatory
•  The operator and the patient

Operatory Preparation

1. The circulator (non-sterile assistant) should begin to prepare the operatory while the sterile assistant scrubs. If there is only one assistant, the operatory should be prepared prior to the scrub.

2. All walls should be wiped down with an antiseptic from 48 inches to the floor. The floor should also be cleaned. If the operatory is exclusive, this can be done the evening before the procedure.

3. The circulator does the following preparation:

•  Open the pack away from the body, being careful to only touch the outer edges and place on a table. Do not touch the sterile contents of the pack or lean over the pack.
•  Remember? the circulator should stay at least 12 inches from the sterile field at all times and must not reach across the sterile field for any reason.
•  Carefully add the sterile gloves to the pack by peeling open the pack, again away from the body, and dropping them onto the sterile field.
•  A regular table or tray should be set up for non-sterile items.

4. The sterile assistant enters the operatory with wet hands after performing the scrub. Using a sterile towel from the opened pack dry hands from the fingertips to the elbow. Reverse towel for the second hand and arm.

5. The sterile assistant grasps and unfolds the gown from the pack and steps into it with both arms simultaneously, leaving hands within the sleeve. Don't go past the cuff. Remember, your hands are disinfected, not sterile.

6. The circulator ties the gown from behind at the inner closure and neck.

7. The sterile assistant puts on the sterile gloves as follows:

•  Open the glove pack with the hands still within the sleeve.
•  Use the cuff of the gown to pull up the cuff of the glove over the cuff of the gown.
•  Extend your hand into the glove.
•  Repeat for the other hand.
• Keep hands at chest level.

8. The circulator pours sterile water onto a sterile towel, being careful not to touch the towel. The sterile assistant and later the doctor will use this towel to wipe off gloves to remove all powder to avoid contamination of instruments which can affect some procedures.

9. The circulator assists the sterile assistant in "turning the gown" as follows:

•  The sterile assistant separates the short ties from the card and hands the card to the circulator being careful not to touch the circulator.
• The sterile assistant turns, wrapping the gown around the body and grasps the tie as the circulator pulls the card away.
•  The sterile assistant ties the gown around the waist.

The sterile person is considered sterile from the nipple line to the waist level and from the front of the arm to the fingertips. For this reason, the sterile assistant should keep hands above the waist area and below the nipple line.

10.The sterile assistant completes the operatory prep as follows:

•  Open stand covers and place on the instrument tray or stand.
•  Place a sterile towel on the instrument tray or stand.
•  Tape a suture bag to the side of the instrument tray for refuse such as bloody gauze. After the procedure this can be disposed of in a red hazard bag.
•  Drape all monitoring devices and equipment, even those that might not be used.
•  Apply headrest covers to chair and light handle covers.
•  Place tubing on the suction and water tubes. It is sometimes easier to cover the suction tube if the suction is turned off at the main switch.

Prepared Operatory

 11. Prepare the instruments as follows:

•  The circulator opens the outer wrapper of the sterile instruments.
•  The sterile assistant removes the instruments to the tray, arranging according to use.

Instrument Tray

Any item which can not be autoclaved should be sterilized the night before by placing in a glass container with cidex or sponicide following the manufacturer's directions. Because of the risk of seepage, do not soak anesthetic carpules. You can however, spray them down 30 minutes prior to use.

12. It is recommended having two or three extra sets of sterile gloves in case the circulator needs to assist by mixing bone, etc. Extra masks, head covers and shoe covers should also be available in case other persons need to enter the operatory

Any persons who enter the operatory during the procedure should wear a mask, head cover and shoe covers.

Operator and patient preparation

The patient after being comfortably seated on dental chair is prepared according to ensuing procedure. The sterile assistant drapes the patient using sterile towel clip. Extra oral and intra oral preparation is done using betadine solution.Operator prepares taking the following parameters into consideration:

Hand Washing

Hand washing is considered the single most important measure to reduce the risk of transmitting organisms to patients and HCWs (health care workers). The purpose of washing is twofold: to reduce the both transient and resident flora for the duration of a procedure to protect the operator in the event that there is non-intact skin on the hand. Additionally, in the event that the gloves become non-intact during the procedure (unknown to the operator), this reduces the numbers of organisms to which the patient will become exposed.

Although hand washing depends primarily on a mechanical effect and any liquid soap is acceptable, because skin bacteria can rapidly multiply under gloves ifn hands are washed with soap that is not antimicrobial, thorough hand washing with a chemically active anti-microbial soap is recommended. Bar soaps are discouraged. For persons with chapped hands, consultation with a dermatologist

and use of emollients is recommended.

The following agents have been found to be effective:

a) 2-4% CHLORHEXIDINE

b) 0.3-1% TRICLOSAN

c) 0.6% PARACHLOROMETAXYLENOL (PCMX)

d) 60-70% PROPANOL

In addition, chlorhexidine and triclosan exhibit substantivity or a residual effect.Although use of alcohol-based hand rubs as an alternate method of hand hygiene,this method is not used in the Faculty clinics.

Wash Technique

Use of artificial nails is contraindicated as is use of colored nail polish. Nails should be short enough to allow thorough cleaning and to prevent tears. Sharp or broken nails encourage glove tearing and should be avoided.All hand jewelry should be removed,however, it is not the purpose of the infection control program to alienate the reader on personal or religious grounds, therefore only those rings which are significantly raised and/or are multifaceted and may cause injury to the patient or readily cause glove tears should be removed. Watches or bracelets should be maintained under the cuffs of the clinic jackets to protect the wearer from spatter of blood and saliva.Hands are always washed at the start and end of each clinic session, morning and afternoon. This has formerly been called the ‘long wash technique’ and differs from usual technique only by the additional cleaning of fingernails which should be done anytime there is visible soil under the fingernails.

a) wet hands from fingertips to wrist with cool water, wet nailbrush and place soap

b) clean the fingernails with a nailbrush 15 seconds or until visible soil is removed

c) rinse with cool water 15 seconds or until all traces of soap are removed

d) place soap on hands and scrub hands vigorously

e) rinse with cool water until all traces of soap are removed

Although any liquid soap would be adequate, an anti-microbial soap is the only soap available at each operatory.Infection Control

The wash without the use of a nail brush is used:

1) Prior to glove placement and following glove removal.

2) After barehanded touching of inanimate objects likely to be contaminated by blood or saliva

3) Before leaving the dental operatory

This shorter handwash technique is as follows:

a) wash the hands using a liquid soap for 15 seconds

b) rinse under running water for 10 seconds or until all traces of soap are removed

c) dry thoroughly with one or two paper towels and ensure proper drying

Barrier Techniques - Personal Protective Equipment (PPE)

The use of personal protective equipment (PPE) - clothing, masks, eyewear, and gloves - is part of routine dental treatment.

Personal protective equipment is placed in the following order:

1. clothing

2. mask

3. glasses

4. wash hands, place gloves

Barriers are removed in the following order:

1. gloves

2. mask

3. glasses

4. wash hands

Protective clothing

rotective outerwear is worn to reduce exposure to debris in spatter. Clinic jackets should have long sleeves, a high neck, and elasticized cuffs. Outerwear should be tidy and professional in appearance: ironed, buttons or snaps all in place, and buttoned fully.In all cases, clothing must be changed daily, although clothing that has become visibly soiled must be changed immediately. Contaminated clinical wear is taken home in a plastic bag and laundered using a high temperature cycle (60-70°C) with a normal bleach concentration followed by machine drying (100°C or more), (or dry cleaned) and pressed.Use of disposable gowns may be considered when performing surgical procedures and treating known carriers of infectious diseases (e.g. HIV positive and HBsAg positive patients). This is done to protect the person or persons performing the\ laundry.

Following patient care, surgical gowns and protective clothing is considered contaminated. Because of this, it is not to be worn outside of the clinic environment in lectures, leisure or eating areas. If contaminated clothing cannot be changed, wear a clean lab coat over top as a second choice. Because there is no simple way to tell which clothing is contaminated, once placed, all outerwear is considered contaminated.

Masks

Masks are to be worn when procedures that result in aerosol production are performed. Protection from these masks only affords protection for those particles 5μm and larger. In order to afford even this protection, the mouth and the nose have to be covered. Masks must also be worn if dental personnel have transmissible respiratory infections.

To ensure that the barrier protection afforded by a mask is not compromised:

 place and adjust the mask to cover the mouth and nose completely prior to placement of gloves and then is not touched again until it is removed. If a mask should slip and it is moist, remove gloves, remove the mask, wash,place clean mask and gloves. If the mask does not require changing, place overgloves, replace overgloves with new ones, and then place the mask with the overgloves and dispose the overgloves.change masks when moist or visibly soiled  remove when patient treatment is complete, when using the phone, or leaving the clinic: remove by the elastic or tie strings, not from the front of the mask itself and discard  do not remove partially and leave dangling from the neck, on countertops, in the hands, or in pockets - once a mask is removed, it is discarded

 do not touch masks with contaminated gloves

Protective Eyewear

Protective lenses must be worn by dental personnel:

1. when performing procedures that can cause spatter or aerosols - including laboratory procedures

2. when performing procedures that produce projectiles - including laboratory procedures

3. when working with or in proximity to chemicals which emit fumes - especially in the laboratory

4. when it is likely that unprotected eyes will be exposed to any type of physical injury or splashes from corrosive or toxic chemicals (e.g. sodium hypochlorite)- including the laboratory

Everyday eyewear may not provide sufficient protection from spatter - special protective glasses, or goggles are required. Sideshields on the glasses increase the level of protection. If a face shield is worn, a mask is still required under the shield.

Protective lenses must be worn by patients, students, and clinical and support staff during active patient care.

Gloves

Gloves are task specific. The different types of gloves worn in the dental office are:

i)Examination gloves

ii) Over or cover gloves

iii) Utility gloves

iv) Undergloves

v) Surgical gloves

Gloves reduce hand contamination by 70-80%, prevent cross-contamination and protect patients and HCW from infection. The use of gloves does not eliminate the need for hand washing both prior to placement and following removal.

i)Examination Gloves - latex, vinyl, nitrile, neoprene

Gloves are worn whenever contact with blood, saliva, mucous membranes or blood/saliva-contaminated objects or surfaces are anticipated and under utility  gloves during cleaning.A new pair of gloves is worn for each patient. Once treatment gloves have been placed, nothing else is touched other than the patient and instruments, equipment, and supplies that have been prepared solely for the use of that patient. Treatment gloves and mask are covered with overgloves when leaving the operatory. When leaving the clinic, even to go to the sterilization bunks, treatment gloves are removed.

Gloves (and mask) are removed when using the telephone Hands are washed prior to placement and upon removal of treatment gloves

ii) Overgloves /covergloves

The purpose of these gloves is to use time more efficiently and to protect the skin on the hands through minimizing the number of times that examination glovesare removed and discarded and hands washed during an appointment with a single patient. Care must be taken to avoid contamination to the outside of the overgloves by touching your clothing, hair, mask, or glasses. Overgloves are not used directly on any item that will be used in the mouth eg. rubber dam, fluoride trays, polishing cups, soflex discs.

Overgloves are used when:

•  supplies or equipment are retrieved or returned to the Dispensary or from the unit mobile
•  the operator is charting
•  obtaining supplies from the mobile with the use of the cotton forceps

Any item that will be used directly in the mouth is NOT TO BE HANDLED

DIRECTLY with overgloves.

Location of Overgloves

•  taped to the sides of the mobile cabinets for procedures such as patient examination and charting during non-aerosol producing procedures
•  on the paper towel dispenser (right-handed students) or the chart holder (left- handed students) and covered by a bib for aerosol or spatter producing procedures

iii) Utility Gloves

Because of the increased risk of percutaneous injury during instrument cleaning (100% of the Faculty incidents reported in academic year 2003/04), heavy-duty utility gloves are used during all disinfection and cleaning procedures. For post- op cleaning, treatment gloves are worn under utility gloves to afford protection to the operator when placing the utility gloves in their sterilization bag. After use they are to be washed, dried and bagged with nail and suction brushes. Student name is properly marked on bag before transport to Central Sterilization.

iv) Undergloves

These are a cotton glove worn under the treatment glove for those operators experiencing discomfort to the skin on the hands. These must be replaced following each patient, are washed following each patient and should be washed with outerwear.

Intraoral Barrier Techniques (Barrier Techniques continued)

1. Rubber dam

A rubber dam is used whenever possible for improved vision and access and to reduce dental personnels' exposure to microorganisms in patients' blood and saliva. (For handling of the rubber dam and rubber dam punch, please refer to "During Treatment" procedures.)

2. Pre-procedural mouth rinse

Patients' use of a an anti-microbial mouthwash of 0.12% chlorhexidinet luconate solution for 30 seconds prior to intra-oral procedures will reduce the number of viable oral organisms. No scientific evidence indicates that pre-procedural mouth rinsing prevents clinical infections among oral health care workers. However, studies have shown that levels of oral microorganismsm are reduced during routine dental procedures with rotary instruments, particularly those in which a rubber dam cannot be used such as use of a prophylaxis cup or ultrasonic scaler.