What are the guidelines for dental ADA procedure and patient care?

Dental ADA Procedures and Patient Care Guidelines

Infection Control and Personal Protective Equipment

Dental healthcare workers must implement strict infection control protocols including handwashing before and after each patient, using fresh gloves between patients, and wearing appropriate protective equipment during all procedures that may generate splatter or aerosols. 1

Hand Hygiene Protocol

• Wash hands before glove placement and immediately after glove removal between every patient 1
• Wash hands after touching any contaminated surfaces or instruments, even when gloved 1
• Use plain soap for routine examinations and nonsurgical procedures 1
• Use antimicrobial surgical handscrub for all surgical procedures 1
• Remove gloves immediately if torn, cut, or punctured during procedures, wash hands thoroughly, and reglove before continuing 1

Glove Management

• Never wash, disinfect, or sterilize gloves for reuse—this causes "wicking" (liquid penetration through undetected holes) 1
• Always use fresh gloves between patients without exception 1
• Healthcare workers with exudative lesions or weeping dermatitis on hands must refrain from all patient care until resolved 1

Protective Equipment Requirements

• Wear chin-length face shields or surgical masks with protective eyewear whenever splashing or spattering is likely 1
• Change masks between patients or during treatment if they become wet or moist 1
• Clean face shields and protective eyewear with appropriate cleaning agents and disinfect when visibly soiled 1
• Wear protective gowns, laboratory coats, or uniforms when blood or body fluid contamination is likely 1
• Change protective clothing at least daily or immediately when visibly soiled 1
• Remove all protective garments before exiting patient care or laboratory areas 1

Surface Protection and Aerosol Control

• Cover difficult-to-clean surfaces (light handles, x-ray unit heads) with impervious-backed paper, aluminum foil, or plastic 1
• Remove coverings while gloved, discard, then wash hands before applying clean coverings 1
• Use rubber dams, high-velocity air evacuation, and proper patient positioning to minimize droplet and aerosol formation 1
• Employ splash shields in dental laboratories 1

Sharp Instrument and Needle Safety

Never recap needles using both hands or any technique that directs the needle point toward any body part—use only the one-handed scoop technique or a mechanical holding device. 1

Needle Handling Protocol

• Place all used disposable syringes, needles, scalpel blades, and sharp items in puncture-resistant containers located as close as practical to the use area 1
• Never bend or break needles before disposal as this requires unnecessary manipulation 1
• For nondisposable aspirating syringes, recap needles before removal using only approved one-handed techniques 1
• For multiple injections with a single needle, place the unsheathed needle where it cannot cause contamination or accidental needlesticks 1

Instrument Sterilization and Disinfection

Classification System

• Critical instruments (penetrate soft tissue or bone): Must be sterilized between uses 1
• Semicritical instruments (contact mucous membranes but don't penetrate): Require high-level disinfection or sterilization 1
• Noncritical instruments (contact intact skin only): Require intermediate to low-level disinfection 1

Medication and Injection Safety

• Use single-dose vials for parenteral medications whenever possible 1
• Never combine leftover contents of single-use vials for later use 1
• For multidose vials: cleanse access diaphragm with 70% alcohol before each entry, use sterile needle and syringe without reusing either component, keep away from patient treatment areas, and discard if sterility is compromised 1
• Use fluid infusion and administration sets for one patient only 1
• Use all single-use devices for one patient only and dispose appropriately 1

Antibiotic Prophylaxis Guidelines

For Cardiac Conditions (Endocarditis Prevention)

Antibiotic prophylaxis for endocarditis prevention is recommended only for the highest-risk cardiac patients undergoing high-risk dental procedures—specifically those with prosthetic valves, prior endocarditis, certain congenital heart defects, or cardiac transplant with valvulopathy. 1

• High-risk dental procedures include manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa (including routine cleanings) 1
• Poor oral hygiene and periodontal disease, not dental procedures themselves, cause the vast majority of endocarditis cases originating in the mouth 1
• Maintaining optimal oral health through daily activities is more important than prophylaxis for dental procedures 1
• The 2017 AHA/ACC guidelines expanded prophylaxis to include patients with transcatheter prosthetic valves and prosthetic material for valve repair 1

Common pitfall: A 2018 Taiwan database study found no clinically significant association between dental treatment and endocarditis risk, suggesting no evidence supports prophylaxis even in high-risk patients 1. However, current AHA guidelines still recommend prophylaxis for the highest-risk patients, representing ongoing controversy in the evidence.

For Prosthetic Joint Infections

In general, antibiotic prophylaxis is not recommended for patients with prosthetic joint implants undergoing dental procedures, as dental procedures are not risk factors for subsequent implant infection. 1

• The 2013 ADA/AAOS joint guideline recommends discontinuing routine prophylaxis for prosthetic joint patients 1
• The 2015 ADA guideline states prophylactic antibiotics should not be given for prosthetic joint implant patients 1
• The 2017 AAOS/ADA guideline identifies specific high-risk patients who may warrant prophylaxis: those with AIDS, active cancer, rheumatoid arthritis, solid organ transplant on immunosuppression, or inherited immune deficiency diseases 1
• Among 64 clinical scenarios analyzed, prophylaxis was appropriate in only 12%, may be appropriate in 27%, and rarely appropriate in 61% 1
• Multiple case-control studies found no statistical association between dental procedures and prosthetic joint infections, and prophylaxis did not reduce infection risk 1
• Daily activities like tooth brushing, flossing, and chewing cause bacteremia more frequently than dental procedures 1

Important caveat: Patient preference should play a significant role in the decision, and the discussion should involve the patient, dentist, and orthopedic surgeon 1

Dental Infection Treatment

Surgical intervention (drainage, debridement) is the cornerstone of treatment for dental infections and must be performed before or concurrent with antibiotic therapy. 2

Treatment Algorithm

1. Primary treatment: Surgical drainage or debridement 2
2. Adjunctive antibiotic therapy: Amoxicillin 500 mg three times daily for 5 days when systemic involvement or risk of spread exists 2
3. For inadequate response: Switch to amoxicillin-clavulanic acid 2
4. For penicillin allergy: Use clindamycin 2

Indications for Antibiotics

• Systemic involvement (fever, lymphadenopathy) 2
• Immunocompromised patients 2
• Diffuse swelling or infections extending to cervicofacial tissues 2
• Following appropriate surgical intervention for acute dentoalveolar abscesses 2

Critical pitfall: Never prescribe antibiotics as sole treatment without addressing the underlying dental issue through surgical intervention 2

Special Populations and Medical Clearance

Anticoagulation Management

• Do not suspend anticoagulation or antiplatelet therapies for common dental treatments (cleanings, extractions, restorations, endodontic procedures, abscess drainage, mucosal biopsies) 3

Cardiac Patients

• Avoid elective dental care for 6 weeks after myocardial infarction or bare-metal stent placement 3
• Avoid elective dental care for 6 months after drug-eluting stent placement 3

Liver Disease

• Ascites is not an indication for prophylactic antibiotics before dental treatment 3
• Acetaminophen is the analgesic of choice for patients with liver dysfunction or cirrhosis who abstain from alcohol 3

Chronic Kidney Disease

• Avoid nephrotoxic medications 3
• Provide the dentist with the patient's glomerular filtration rate 3

Cancer Patients

• Patients undergoing chemotherapy may receive routine dental care 3
• Postpone dental care when possible for patients currently undergoing head and neck radiation therapy 3
• Provide detailed history of head and neck radiation therapy to the dentist 3
• Communicate any history of antiresorptive or antiangiogenic therapies to the dentist 3

Pain Management

• Use multimodal, nonnarcotic analgesia for managing acute dental pain 3

Specimen and Extracted Tooth Handling

Biopsy Specimens

• Place specimens in sturdy, leakproof containers labeled with biohazard symbol during transport 1
• If container exterior is visibly contaminated, clean and disinfect or place in impervious biohazard-labeled bag 1

Extracted Teeth

• Dispose as regulated medical waste unless returned to patient 1
• Do not dispose of teeth containing amalgam in regulated medical waste intended for incineration 1
• For transport to educational institutions or laboratories: clean, place in leakproof biohazard-labeled container, and maintain hydration 1
• Heat-sterilize teeth without amalgam before educational use 1