When taking dental radiographs, there is significant potential for cross-contamination of equipment and environmental surfaces with blood and/or saliva if proper aseptic techniques are not practiced. Dental healthcare personnel (DHCP) also can be at risk. Research indicates that oral micro-organisms can remain viable on inert radiographic equipment for up to 48 hours. Similar microbes have been shown to survive in x-ray developer/fixer for periods as long as 2 weeks.^1-4

USING INTRAORAL FILMS HELD WITHIN BARRIER POUCHES

Table 1. Prior to taking x-rays (modified from references 2 to 5).

Step Action 1 Acquire all necessary disposable and heat-sterilized intraoral x-ray accessories 2 Place surface covers on selected clinical contact surfaces 3 Unit-dose necessary supplies, equipment, and instruments 4 Provide patient with appropriate shielding apron 5 Wash hands, dry well, and put on examination gloves 6 Place other types of PPE if necessary

Table 2. While taking x-rays (modified from references 1 to 8).

Step Action 7 Wear gloves while taking x-rays and when handling contaminated films 8 Wear other PPE such as masks, protective eyewear, and gowns if spatter is expected 9 Use films held within FDA-cleared barrier pouches 10 Touch as few surfaces as possible 11 After exposure and with gloved hands, dry each film with disposable gauze or paper towel to remove patient fluids 12 Repeat process until all films are exposed

Table 3. After taking x-rays (modified from references 1 to 8).

Step Action 13 Return reusable film-holding devices to the designated area. 14 Carefully remove the film packets from their protective pouches to avoid contamination of the film surfaces. Allow the films to fall from the pouches into clean paper or plastic cups or onto clean paper towels—avoid touching the transport cups 15 Discard all contaminated disposable materials 16 Remove covers (barriers) from the surfaces protected and discard 17 Disinfect uncovered surfaces that were contaminated while wearing gloves 18 Remove gloves and wash hands properly

Preparing to Take Dental Radiographs
It is important to prepare the area prior to seating the patient. Advanced preparation increases the chances of success. Whenever possible, items used in the mouth should either be single-use, disposable, or sterilized by heat (Table 1).

Taking Dental Radiographs
Gloves should always be worn when taking radiographs and handling contaminated film packets. Other PPE should be used when the spattering of patient body fluids is likely. Ideally, only heat-tolerant intraoral x-ray accessories (eg, film holders and positioning devices) should be used. Some items such as mouth props can either be sterilized or be single-use and disposable (Table 2).

After Taking Dental Radiographs
Care must be taken when peeling or pulling open the protective barriers covering the x-ray films. Patient fluids must not reach either the films or the transport cups. Unsoiled films are the de­sired goal. Handling such items without gloves makes processing much easier in the darkroom and daylight loader^1-4 (Table 3).

Developing Dental Radiographs
Once in the developing area, open film packets with clean, ungloved hands. Holding the tab, films can go into clean plastic cups or onto paper towels. Holding films by their edges, insert them into the processor. Just to be safe, it is best either to cover or to clean and disinfect the surfaces of developing equipment regularly^1-4 (Table 4).

Table 4. Processing x-rays (modified from references 1 to 8).

Step Action 19 Transport films in disposable containers; gloves are not needed because the outside of the films and the containers is not contaminated 20 Discard all contaminated disposable materials 21 Prepare the processing area by unit-dosing out necessary items such as gloves, paper cups, paper towels, film mounts, and paper envelopes 22 Unwrap films and process; hold films only by their edges 23 Label film mounts or film envelopes 24 Disinfect uncovered surfaces of the developing equipment

Table 5. Processing unprotected x-rays (modified from references 1 to 8).

Step Action A Transport films in disposable container cups B Place cups onto paper towels and prepare processing area C Put on new gloves, open film packets, and allow film to fall onto clean paper towels D Dispose of transport cups and empty film packets E Remove gloves and wash hands F Process films by holding them by their edges G Label film mounts and envelopes H Disinfect uncovered surfaces that were contaminated while wearing gloves

Table 6. Extraoral radiographs (modified from references 1 to 8).

Step Action A Wash and dry hands—extraoral cassettes can be handled with ungloved hands B Use sterile reusable or single-use disposable bite guides C If deemed necessary, barrier protect chin rests, head positioning guides, and handgrips D After exposure of the film, ask the patient to remove the bite guide and barrier covers E If patient cannot or will not comply, the DHCP must put on gloves and handle bite guide and surface covers F Remove gloves and wash hands prior to handling film cassettes

USING INTRAORAL FILMS NOT HELD WITHIN BARRIER POUCHES
It is important when handling and processing films not held in protective barriers that they be well wiped off chairside after removal. It is very important either to cover or clean and disinfect any surface that may become contaminated^2,3 (Table 5).

PANORAMIC/ CEPHALOMETRIC X-RAYS
Fewer intraoral pieces of equipment are used when taking extraoral radiographs such as panoramic and cephalometric films. The chances of contamination with patient blood or saliva are greatly reduced. Bite guides should be sterilized or be single-use disposable types. The use of covers over the bite guide is less desirable^2,3 (Table 6).

Daylight loaders commonly have cloth or rubber sleeves, cuffs, or flaps. These are used to allow for the passage of materials in and out of the daylight loader without allowing light to enter. This means that the equipment is difficult or impossible to clean or disinfect. Therefore, it is imperative that an effective yet efficient protocol for aseptic use be established and rigorously maintained. After reviewing the following steps, it should be obvious how useful barrier protected films are^2-6 (Table 7).

DIGITAL X-RAYS AND OTHER TECHNOLOGIES

Table 7. Using daylight loaders (modified from references 1 to 8).

Step Action A Open the lid of the loader and place all necessary items inside: paper towels, plastic cups, and powder-free inexpensive gloves B Place cups containing contaminated films next to clean plastic cups C Close the lid and insert arms into the unit D Put on gloves and select a single-film packet to be processed and open it as aseptically as possible. Repeat until all films have been opened E Allow film to fall onto a clean paper towel F Place all disposable materials into a plastic cup G Remove gloves and place them into a cup H Feed films into the processor, handling them only by the edges (or process films by hand by immersing them in the appropriate chemical-filled cups while wearing a new pair of gloves) I Remove ungloved hands from the unit and wash them J Lift lid and remove processed films—label film mounts or film envelopes K Aseptically remove and dispose of waste materials

Digital radiographic sensors and other high-technology instruments such as intraoral cameras, electronic periodontal probes, colossal analyzers, and lasers come into contact with mucous membranes. Such devices are considered to be semi-critical items. Ideally, they should be cleaned and heat-sterilized or high-level disinfected between patients. However, many cannot be heat-sterilized or undergo high-level disinfection.

SUMMARY
Infection control for dental radiography employs the same materials, processes, and techniques used in the operatory, yet unless proper procedures are established and followed, there is a definite potential for cross-contamination to clinical area surfaces and DHCP. In general, the aseptic practices used are relatively simple and inexpensive, yet they require complete application in every situation.

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References

1. Kohn WG, Collins AS, Cleveland JL, et al; Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings—2003. MMWR Recomm Rep. 2003;52(RR-17):1-61.
   
2. Organization for Safety & Asepsis Procedures. From Policy to Practice: OSAP’s Guide to the Guidelines. Annapolis, Md: Organization for Safety & Asepsis Procedures; 2004:91-97.
   
3. USAF Dental Investigation Service. Infection control practices for dental radiology. Available at: http://www.brooks.af.mil/dis/DOWNLOAD/radiologyinfcontrol.pdf. Accessed April 2004.
   
4. Organization for Safety & Asepsis Procedures. Infection control and dental radiography. Infection Control In Practice. 2003;2(November):1-8.
   
5. Miller CH, Palenik CJ. Sterilization, disinfection, and asepsis in dentistry. In: Block SS, ed. Disinfection, Sterilization, and Preservation. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001:1049-1068.
   
6. Miller CH, Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team. 2nd ed. St Louis, Mo: Mosby; 1998:217-221.
   
7. Haring JI, Jansen L. Infection control and the dental radiographer. In: Haring JI, Jansen L. Dental Radiography: Principles and Techniques. 2nd ed. Philadelphia, Pa: WB Saunders; 2000:194-204.
   
8. Glass BJ, Terezhalmy GT. Infection control in dental radiology. In: Cottone JA, Terezhalmy GT, Molinari JA, eds. Practical Infection Control in Dentistry. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996:229-238.

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Dr. Palenik has held over the last 25 years a number of academic and administrative positions at Indiana University School of Dentistry. These include professor of oral microbiology, director of human health and safety, director of central sterilization services, and chairman of infection control and hazardous materials management committees. Currently he is director of infection control research and services. Dr. Palenik has published 125 articles, more than 290 monographs, 3 books, and 7 book chapters, the majority of which involve infection control and human safety and health. Also, he has provided more than 100 continuing education courses throughout the United States and 8 foreign countries. All questions should be directed to OSAP at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 

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