7.1 Incorporated Clinical Standards: CDC Infection Control & ADA Radiography Guidelines
Key Takeaways
- Failing to follow the CDC's infection control recommendations is professional misconduct under RSA 317-A:17, II(g)(2) and Den 407.01(i)(2).
- Failing to follow the ADA radiographic guidelines adopted by the Board, including Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure, is professional misconduct under RSA 317-A:17, II(g)(1).
- Den 501.01(p) requires licensees to adhere to the ADA's Infection Control and Sterilization guidance (revised October 2022) and X-Rays/Radiographs guidance (revised March 2024).
- CDC dental guidance calls for biological (spore) monitoring of sterilizers at least weekly, and for sterile saline or sterile water as the coolant or irrigant in surgical procedures.
- Every New Hampshire dentist and hygienist needs at least 2 CEUs each biennium in an infection control course that includes CDC guidelines (Den 406.03).
Incorporated Clinical Standards
The legal hooks
| Source | What it incorporates | Consequence |
|---|---|---|
| RSA 317-A:17, II(g)(1) | Current ADA guidelines as adopted by the Board: Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure and Recommendations in Radiographic Practices | Failure to follow = professional misconduct |
| RSA 317-A:17, II(g)(2) | CDC Infection Control Recommendations | Failure to follow = professional misconduct |
| Den 407.01(i) | The same ADA radiographic documents (the Recommendations in Radiographic Practices update appeared in JADA, January 1989) and the CDC recommendations | Misconduct |
| Den 501.01(p) | ADA guidelines for Infection Control and Sterilization (revised 10/2022) and X-Rays/Radiographs (revised 3/2024) | Ethical duty; violating a Board rule is misconduct under Den 407.01(r) |
The same standards reach every level of the dental team:
- Dentists and hygienists: at least 2 CEUs each biennium in infection control, in a course whose syllabus includes the CDC's Infection Prevention and Control Guidelines and Recommendations (Den 406.03(a)(3), (b)(3)).
- Traditional dental assistants: a 4-hour infection control qualification that follows current CDC recommendations for the dental office and laboratory, with a written exam, before processing instruments (Den 302.06(b); Den 404.01(c)).
- Public health hygienists: must agree to follow CDC infection control guidelines to obtain public health supervision status (Den 405.02(a)(5)). CPHDHs complete a 4-hour course on infection control in public health settings (Den 302.08(a)(3)c).
- Volunteer licensees: 2 CEUs of infection control each biennium (Den 301.05(g)).
- Radiography by assistants: requires the Den 302.06(i) qualification (including radiation safety and the DANB radiology exam) and direct supervision. Hygienists take radiographs under general supervision (Den 405.01(a)(9)), and CPHDHs are limited to bitewings, occlusal, and periapical images (RSA 317-A:21-e, I(h)).
Core CDC infection control concepts
The CDC's Guidelines for Infection Control in Dental Health-Care Settings (2003) and its Summary of Infection Prevention Practices in Dental Settings (2016) set the expectations Den 406.03 and RSA 317-A:17 point to.
Standard precautions
Standard precautions apply to every patient, regardless of suspected or confirmed infection. They treat blood, all body fluids, secretions, and excretions (except sweat), non-intact skin, and mucous membranes as potentially infectious. Their elements are:
- Hand hygiene
- Personal protective equipment (gloves, masks, eye protection, protective clothing)
- Respiratory hygiene and cough etiquette
- Sharps safety (engineering and work-practice controls)
- Safe injection practices
- Sterile instruments and devices
- Clean and disinfected environmental surfaces
Instrument processing: the Spaulding categories
| Category | Contact | Processing |
|---|---|---|
| Critical | Penetrates soft tissue or contacts bone (forceps, scalers, surgical burs) | Sterilize (heat) |
| Semicritical | Contacts mucous membranes or non-intact skin (mirrors, amalgam condensers, handpieces) | Sterilize; if heat-sensitive, at minimum high-level disinfection |
| Noncritical | Contacts intact skin (BP cuffs, radiograph head) | Low- or intermediate-level disinfection |
Sterilizer monitoring
- Mechanical indicators (time, temperature, pressure) are checked each cycle.
- A chemical indicator goes inside each package, with an external indicator too if the internal one cannot be seen from outside.
- Biological indicators (spore tests) are run at least weekly, and for every load containing an implantable device.
After a positive spore test, the sterilizer comes out of service and the cause is investigated. Instruments are recalled as far as possible if repeat testing confirms failure.
Dental unit water quality
- Routine (nonsurgical) treatment water should meet EPA drinking water standards: no more than 500 CFU/mL of heterotrophic bacteria. Offices use the equipment manufacturer's recommended methods and monitoring.
- Oral surgical procedures, meaning incision, excision, or reflection of tissue that exposes normally sterile areas of the oral cavity, use sterile saline or sterile water as the coolant or irrigant, delivered by devices designed for sterile irrigation, not dental unit water.
Core ADA radiography concepts
The ADA and FDA radiographic recommendations, which RSA 317-A:17, II(g)(1) incorporates, rest on two ideas:
- Patient selection: radiographs are prescribed based on the individual patient's needs after a clinical examination and history, not on a fixed schedule for everyone.
- Limiting exposure: keep radiation as low as reasonably achievable, for example by using the fastest image receptor compatible with the diagnostic task and rectangular collimation.
Because Den 501.01(p) points to the ADA's current radiograph guidance, licensees must follow the current version of that guidance.
Worked scenario
An OPLC inspector reviewing an office after a complaint finds that:
- (a) the autoclave spore-test log shows tests every 5 to 6 weeks;
- (b) the associate dentist irrigates surgical extraction sites with dental unit water; and
- (c) the office takes full-mouth series on every adult every year regardless of clinical findings.
Each finding departs from standards incorporated by law:
- (a) and (b) conflict with CDC infection control recommendations (weekly biological monitoring; sterile coolant or irrigant for surgery).
- (c) conflicts with the ADA patient-selection recommendations.
Under RSA 317-A:17, II(g) and Den 407.01(i), each is a ground for discipline. None is excused by the office's own written protocol or the dentist's personal preference.
What is the legal effect in New Hampshire of a dentist's failure to follow the CDC's infection control recommendations?
An oral surgeon's associate uses water from the dental unit's high-speed handpiece line to cool a bur while sectioning an impacted molar through a surgical flap. Which incorporated standard does this conflict with?
How often does CDC dental guidance, incorporated through RSA 317-A:17, II(g), call for biological (spore) testing of heat sterilizers?