Measures in (sterile) surgical procedures in the oral cavity - Practical infection prevention at the chair

Measures in (sterile) surgical procedures in the oral cavity - Practical infection prevention at the chair
There is a (sterile) surgical procedure when 'tissues are separated'. This creates contact with sterile tissue, in which bone is exposed to instruments, materials, fluids and in the air of the treatment room. The risk is an increased chance of an infection.

Measures in (sterile) surgical procedures in the oral cavity


There is a (sterile) surgical procedure when 'tissues are separated'. This creates contact with sterile tissue, in which bone is exposed to instruments, materials, fluids and in the air of the treatment room. The risk is an increased chance of an infection.


In the case of surgical procedures, additional measures must be taken with regard to the regular measures for infection prevention in oral health care because of the sterility of the tissues approached. The general measures are not sufficient. To prevent contamination and infections in these cases, it is necessary to ensure sterility and to 'work sterile'.


A distinction is made between CH-1 and CH-2 surgical procedures in the oral cavity and thus also in the preventive measures that need to be taken. The infection risks for both categories are different, and this ultimately determines the difference in preventive measures and the circumstances in which the interventions are carried out.


In CH-1 procedures, it is necessary to make a more extensive mucoperiostal flip-up. Examples include: placement of dental implants, surgical removal of deeply impacted elements and radices and a root point operation with or without apical closure. In doing so, it must be prevented that exogenous micro-organisms (for example, from the environment, from the skin or from the water) can be contained. This can be achieved by working with sterile instruments, sterile gloves and materials and a sterile worktop.


With CH-2, there is only a local mucoperiostal reversal. Examples include: simple closure antrumperforations, flap surgery for periodontal purposes. CH-2 procedures assume that the area of operations does not have to be sterile because there is an open connection between the mouth and the wound during the healing process. Again, however, exogenous contamination must be prevented as much as possible, but sterility of the working environment is not necessary. A clean worktop with sterilized instruments is sufficient.


The starting point for performing surgical procedures, both for CH-1 and CH-2, is that this should not lead to any damage to the patient, including no complications such as an infection.


If this is the case, we speak of iatrogenic damage: a damage caused by medical intervention. Infections that have arisen as a result of medical or technical care are called care-related infections.


The additional measures for surgical procedures concern the clothing of the team, reconditioning of sterile instruments, layout of the work area, cooling water and air quality in the treatment room.



Clean or sterile clothing

Although the KNMT infection prevention guideline does not prescribe sterile clothing for certain types of surgical procedures, it can be encountered in daily practice that the operating team still wear sterile clothing. The relevant practice chooses from the perspective of infection prevention and therefore also from quality and safety considerations.


Sterile clothing from the treatment team


Sterile cloths and covers


Sterile instruments


Clean clothing

The Infection Prevention guideline in dental practices, including that of the WIP (Working Group on Infection Prevention), shows that clean clothing is sufficient for CH-1 procedures. The clothing does not have to be sterile. It then concerns interventions in an independent treatment room, not in an operating room.


In an independent treatment room, only the appropriate procedures may be performed. The KNMT scientific association has drawn up a classification (CH-1 and CH-2 interventions) for this.


Primarily, no sterile clothing - surgical clothing - has to be worn when performing procedures in a treatment room. The WIP indicates that for oral diseases and oral surgery in an independent treatment room all interventions that take place under local anesthesia can take place. The WIP stipulates in the Infection Prevention guideline in dental practice that the dentist and assistant wear a clean protective coat. So with every new patient, the jacket must be changed. This jacket can be worn over the normal work clothes. The question, however, is how do you guarantee that this clothing is clean?



Sterile gloves

The use of sterile gloves applies only to CH-1 surgical procedures. For CH-2 procedures, at least disposable gloves should be worn. Although they do not have to be sterile, you may find in a practice that sterile gloves are still worn. The same argument applies as for sterile clothing.


There are a number of requirements for CH-2 procedures, which you can call the minimum requirements. Everything that someone wants to do extra is allowed.


The treatment team wears protective glasses and a mouth-nose mask. This applies to both CH-1 and CH-2 procedures.


A special course is recommended to adequately practice this 'sterile standing' before organizing it for the first time. A large part of the MBO courses as a dental assistant offers the optional course "Surgery in dentistry" starting from course year 2017-2018 or 2018-2019.


The field of action in surgical procedures in dental practice

A distinction is made between CH-1 and CH-2 surgical procedures.


For category CH-1 surgical procedures in the oral cavity, a sterile working tablet is used. You create a sterile working field by:


  • Always work with assistance;
  • The treatment room to be set up for sterile work;
  • Operator and assistant to wear clean work clothing and personal protective equipment (mouth-nose mask and protective goggles);
  • Dismantle the area around the mouth with 0,12-0,2% chlorhexidine or hand alcohol and cover with a sterile cloth;
  • Put sterile instruments and sterile materials on a sterile working tablet;
  • Use sterile gloves, (drill) covers and handles;
  • To use preoperative hand disinfection; see Hand hygiene guideline;
  • Sterile water or sterile physiological saline solution can be used as cooling for rotating instruments and for (after) flushing the wound area.


In category CH-2 surgical procedures in the oral cavity, a clean working tablet is used. You create a clean work field by:


  • The operator and assistant must wear clean work clothing and personal protective equipment (mouth-nose mask and protective goggles);
  • Sterilize sterilized instruments and materials on a clean working tablet.



Hand hygiene during a surgical procedure

Non-sterile gloves are worn during non-surgical dental procedures and cleaning or disinfection of the hands is sufficient. For surgical procedures, a distinction is made between CH-1 and CH-2 procedures.


For CH-1 dental surgeries, sterile gloves are always worn and preoperative hand disinfection is used.


For CH-2 procedures, non-sterile gloves and ordinary hand hygiene are sufficient.


In preoperative hand disinfection, the hands are first cleaned with soap and water and then dried. The hands are then rubbed with the hand disinfectant for three to five minutes (the time indicated by the hand sanitizer manufacturer).


Only administer preoperative hand disinfection prior to CH-1 surgical procedures. Performing preoperative hand cleaning and hand disinfection in a first surgical procedure, in chronological order:


  • Clean hands and wrists with soap and water at the start of the working day.
  • Use a soft brush with visibly dirty hands.
  • Pay special attention to nails and knuckles.
  • Then dry the hands and wrists completely with disposable towels.
  • Then rub the hands with hand disinfectant so that the hands and wrists remain wet for the period prescribed by the manufacturer.
  • Continue rubbing the hands until the disinfectant has dried.
  • Only remove sterile gloves when the hands and wrists are dry.


At follow-up operations:


  • When employees of the treatment team perform multiple surgical procedures with other patients, only hand disinfection between the various procedures will suffice. Only when the hands are visibly dirty, they are first cleaned with soap and water.


Sterile working environment

The treatment room must be easy to clean and disinfect and there must be no unnecessary furniture in the room. There must be a good washing area for the hands and of course also for hand disinfection. There must be nothing on the worktop that is not needed during the procedure. There is also a storage for sterile instruments and materials and the current requirements must be met.


Treatment room is basically empty


In CH-1 surgical procedures, the field is sterile covered with sterile cloths. This concerns both the direct working environment around the mouth and the worksheet. Sterile packages can be put together for this and are sometimes even 'custom made' supplied by some suppliers with all the upholstery materials of their choice.


Sterile working field


The hoses of extractors and drills are provided with sterile (drill) covers. Training is also an important part of preparing surgical treatments for correct fitting.


Handles of surgical lamp and treatment unit are provided with sterile protective covers or with sterile foil.



Sterile water

Cooling water used in drilling or rinsing the wound should always be sterile. This usually also applies to the use of a physiological saline solution during manual cooling / rinsing. These sterile liquids can be kept for up to 24 hours after opening the package.


Sterile cooling water with separate pump installation


It is important that the ultrasonic equipment and required corner pieces are provided with a cooling water system. Do not use the regular connection of the unit for this! A special water pump for sterile water is required.


Sterile treatment rooms

It is important to prepare all instruments and materials as soon as possible in advance, with a work supply of gloves on the worktop. Prevent unnecessary exposure of sterile instruments to the air. Open the package and as short as possible before the procedure.


Only in unforeseen circumstances would a turnaround assistant have to provide something...


According to the Infection Prevention guideline in dental practices, the use of air conditioning in the treatment room is permitted during surgical procedures. If the air conditioning is polluted, extra particles and micro-organisms can be blown into the room. This will cancel out the entire sterility that you have created. And the question is whether this is a good point in implantations. You would then have to make demands on the quality and maintenance of the air conditioning.


Footnote from the Infection Prevention guideline for oral care practices:


The extensive sterility measures in certain CH-1 implantological and periodontal interventions are based on the results of systematic literature research and where no research data are available on consensus among experts and on legislation and regulations. The working group on the Infection Prevention guideline in oral care practices is of the opinion that there is an urgent need for additional research, which maps out the added value of extensive sterility measures in relation to the contusions, complications and the clinical outcome.