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Dental Article Review and Testing
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Infection control practices in dental radiology
Infection Control
Joseph A. Bartoloni, DMD | David G. Charlton, DDS, MSD
The potential for cross-contamination in dental radiology is extremely high, especially
when intraoral radiographs are exposed and processed. This report describes specific
infection control practices that are recommended to decrease the potential for cross-
contamination in dental radiology and reduce the likelihood of disease transmission.
Received: February 21, 2002
Since the beginning of the AIDS epidemic,
an increased emphasis has been placed on
medical and dental work practices to min-
imize bloodborne pathogen exposure. In
1990, public concern regarding dental in-
fection control grew after the CDC report-
ed a possible clinic-acquired HIV trans-
mission within the dental setting.1 In
1991, OSHA established the Bloodborne
Pathogens Standard to protect employees
from exposure to potential pathogens in
human body fluids.2 This document man-
dated that personal protective measures be
implemented in health care settings to
safeguard employees who could come in
contact with potentially infectious materi-
als, including blood or saliva.
Dental patients and dental health care
workers (DHCWs) are exposed to a num-
ber of infectious disease agents during the
delivery of treatment. To minimize the
risk of cross-contamination (that is, the
passage of microorganisms from one per-
son or inanimate object to another) that
may transmit disease, both the CDC and
the ADA have published dental infection
control guidelines, which are revised peri-
odically to include the most updated
information.3,4
Because blood and saliva can harbor
life-threatening microbes, health care
workers providing dental care may be ex-
posed to a variety of pathogens (see
Table 1). Studies have shown that opera-
tory equipment, surfaces, and materials
used during treatment can become heav-
ily contaminated through cross-contami-
nation from saliva and blood-coated
hands as well as gloved hands, which can
serve as a source for the indirect spread of
microorganisms.5-8 Infection control
practices are designed to create and
maintain a safe clinical environment to
eliminate or minimize disease transmis-
sion during patient treatment.
264 General Dentistry
| Diane J. Flint, DDS
Accepted: April 30, 2002
In an effort to reduce transmission of
bloodborne pathogens between DHCWs
and patients, in 1988 the CDC empha-
sized the use of Universal Precautions,
meaning that all patients should be con-
sidered potentially infectious and that the
same infection control procedures should
be used for every dental procedure where
a DHCW could come into contact with
blood or saliva.9 In 1996, the CDC devel-
oped guidelines combining Universal
Precautions and body substance isola-
tion. These guidelines are known as
Standard Precautions, which consider all
body fluids, secretions, and excretions
(except sweat) as potentially infectious,
regardless of whether they contain
blood.10 Initially developed for use in the
care of patients in hospitals, Standard
Precautions gradually have replaced Uni-
versal Precautions in all types of health
care settings.
To prevent or reduce the risk of work-
related infections for DHCWs and their
patients, all dental facilities should have a
well-written, frequently updated infec-
tion control plan. The plan should in-
clude policies and standard operating
procedures for patient care, including
dental radiology.
Infection control practices for dental
radiography, like those utilized in the
dental operatory, are based on Standard
Precautions. The potential for cross-con-
tamination in dental radiology is ex-
tremely high, because taking and process-
ing intraoral radiographs involves a
multi-step process including both intra-
oral and extraoral procedures.
Several studies have confirmed that
cross-contamination occurs during the
exposure and processing of intraoral
films. Rahmatulla et al found that most
high-touch areas in dental radiology, in-
cluding the dental chair headrest adjust-
www.agd.org
ing lock, the x-ray cone, the exposure
control knob, the timer switch, the x-ray
film placement area in the darkroom, the
x-ray film feeding area in the automatic
film processor, and the revolving door to
the darkroom, became contaminated
while taking radiographs.11 White and
Glaze found that the DHCW can transfer
oral microorganisms from the patient’s
oral cavity to radiographic equipment
during routine intraoral radiography.12
These microorganisms remain viable on
radiographic equipment for at least 48
hours. Bachman et al demonstrated that
contaminated films cross-contaminate
radiographic processor equipment, be-
cause the developing process does not de-
stroy the microorganisms.13
Bacteria can survive in used dental
radiographic developer and fixer for up
to two weeks.14 A 1993 report by Stan-
czyk et al discovered that microorganisms
on contaminated radiographic film can
survive the processing cycle, meaning sub-
sequent films frequently become cross-
contaminated within the processor.15 In
addition, the processor and daylight loader
could become contaminated and remain
so even after 48 hours of inactivity.15
A number of articles offer suggestions
and specific information regarding proper
infection control procedures for exposing
and processing dental radiographs.16-36 As
mentioned earlier, infection control prac-
tices in dental radiology are similar to
those used in the dental operatory, in-
cluding the wearing of appropriate per-
sonal protective equipment; handwash-
ing; using surface barriers; cleaning and
disinfecting equipment and environmen-
tal surfaces; and cleaning, disinfecting,
and sterilizing instruments. Each of these
procedures will be discussed in detail.
Personal protective equipment
All DHCWs should wear gloves to prevent
skin contact with blood, saliva, mucous
membranes, and contaminated items or
surfaces. Gloves also should be worn when
taking intraoral radiographs and when
handling contaminated film packets,
equipment, supplies, and instruments.
Powder-free gloves are recommended
 Table 1. Microorganisms that may be present in blood or saliva.

Bacteria Viruses
Mycobacterium tuberculosis HIV
Streptococcus pyogenes Hepatitis B
Streptococcus pneumoniae Hepatitis C
Staphylococcus aureus Herpes simplex 1 and 2
Staphylococcus epidermis Cytomegalovirus
Haemophilus influenza Epstein-Barr
Treponema pallidum Measles rubeola/rubella Fig. 1. To minimize cross-contamination,
Neisseria gonorrhoeae Cold/flu only those items necessary for the procedure
Varicella-zoster should be dispensed. This process is known
as unit dosing.

because powder can affect the film’s
emulsion layer and cause image artifacts.
Gloved DHCWs should either avoid
touching nonbarrier-protected surfaces
or use an overglove, such as an oversized
food handler’s plastic glove. Gloves are
single-use items and should be changed
between patients; they should never be
washed or disinfected for reuse and
should be removed and changed if they
become torn, cut, or punctured during
treatment. It usually is not necessary to
wear impervious gowns, long sleeves,
masks, or protective eyewear during rou-
tine dental radiology procedures as long
as no aerosols, droplets, or spatter are
generated, although these should be con-
sidered when treating patients with gag-
ging problems or respiratory infections,
such as the common cold.
Handwashing
Proper handwashing is one of the most
important means of preventing disease
transmission. All DHCWs should wash
their hands thoroughly before and after
patient treatment (that is, before gloving
and after removing gloves). Ungloved
hands should be washed after touching
any contaminated item or surface. Gloves
are not a substitute for handwashing.
Surface barriers
Any surfaces and objects that may be
touched by contaminated gloved hands
during treatment should be covered with
some type of disposable, impervious bar-
rier such as household plastic wrap, a
plastic bag, plastic sheets or tubing, or
aluminum foil. Surface barriers provide
adequate protection against cross-con-
tamination while eliminating the need to
clean and disinfect surfaces between pa-
tients, which has the additional benefit of
reducing turnaround time. If uncovered
surfaces are contaminated, they should
be disinfected after the patient leaves.
Contaminated surface barriers should be
changed between patients and gloves
should be worn when removing and dis-
carding surface barriers.
Cleaning and disinfection of
equipment and environmental
surfaces
Following a patient’s treatment, all sur-
faces and items contaminated with blood
or saliva should be thoroughly cleaned
and disinfected using a suitable chemical
germicide that provides intermediate-
level disinfection. By definition, interme-
diate-level disinfectants destroy Mycobac-
terium tuberculosis, hydrophilic and
lipophilic viruses, fungi, and vegetative
bacteria but not bacterial spores. Chem-
ical germicides appropriate for use in
dental facilities should be labeled “hospi-
tal-grade” and have an EPA number.
Hospital-grade germicides demonstrate
efficacy against Staphylococcus aureus,
Pseudomonas aeruginosa, and Salmonella
choleraesuis. They also should be tuber-
culocidal, capable of killing M. tuberculo-
sis. The manufacturer’s instructions
should be followed carefully with regard
to dilution, use, and material compatibil-
ity. Heavy-duty utility gloves should be
worn when using chemical germicides.
Cleaning, disinfection, and
sterilization of instruments
and items
Most reusable instruments and items
used in dental radiology are considered
semicritical (contacting the mucous
membrane) or noncritical (contacting in-
tact skin). Reusable semicritical items
such as x-ray film holding and position-
ing devices should be barrier-protected or
treated with a high-level disinfectant at
the very least. High-level disinfectants are
capable of destroying or inactivating all
microbial life (including bacterial spores)
as long as they are used in sufficient con-
centrations and with appropriate contact
times; however, reusable semicritical
items should be sterilized between patient
use. If routine sterilization of semicritical
items is not possible, disposable items
should be substituted. Noncritical items
(for example, the x-ray cone, exposure
button, and lead apron) require only in-
termediate-level disinfection.
The exposure and processing of intra-
oral radiographs are not routinely associ-
ated with blood and saliva splatter but dis-
ease transmission still is possible through
direct contact or cross-contamination.
Therefore, specific infection control prac-
tices for dental radiology are recommend-
ed that should be followed before, during,
and after film exposure as well as during
the processing of intraoral radiographs.
Prior to film exposure, the x-ray expo-
sure area should be prepared using an
aseptic technique, one which breaks the
chain of infection and prevents cross-con-
tamination. All necessary supplies, equip-
ment, and instruments should be pre-
pared before the patient is seated; only the
amount necessary for each procedure
should be dispensed. This concept,
known as unit dosing, is essential for min-
imizing cross-contamination (Fig. 1).
Unit dosing reduces both chairside time
and the DHCW’s contact with environ-
mental surfaces.
The DHCW should barrier-protect
all surfaces that are likely to be touched

May-June 2003 265

 Table 2. Surfaces that
should be protected prior to
radiographic procedures.

Tubehead/yoke
X-ray cone
Control panel
Exposure button
Fig. 2. Surface barriers covering Fig. 3. A surface barrier cover-
Headrest
the tubehead/yoke, x-ray cone, ing the tubehead and x-ray cone.
Headrest adjustment control and headrest.
Chair adjustment control
Work area or countertop

Fig. 4. A surface barrier covering the Fig. 5. A foot switch, used to Fig. 6. A surface barrier Fig. 7. Aseptic dispensing
control panel of an x-ray machine. activate the exposure while completely enclosing the of dental radiographic film
maintaining infection control. remote switch. prior to the procedure.

Table 3. Infection control practices before film exposure.

Before the patient is seated After the patient is seated

The DHCW should unit dose the follow-
ing items: preprocedural mouthrinse;
paper towels; surface disinfectant; surface
barriers; powder-free gloves; radiograph-
ic film(s); sterile or disposable film hold-
ers; paper cups or plastic bags; over-
gloves; lead apron with thyroid collar;
and cotton rolls.
The patient should rinse with a preproce-
dural mouthrinse to reduce the number
of oral microorganisms and minimize the
potential for cross-contamination via
direct contact.
Adjust the headrest and chair position.
Place the lead apron with thyroid collar.
Have the patient remove any items that
may interfere with film exposure (eye-
glasses, dentures, and so forth).
After completing these procedures, the
DHCW should wash his or her hands
thoroughly and don gloves. If using
reusable film-holding devices, they
should be removed from the sterilized Fig. 8. Film barriers. Left: film placed in a
package and assembled. All of these barrier. Right: prepackaged film with a
steps should be performed in the pa- ClinAsept barrier.
tient’s presence.

during the radiographic procedure (see
Table 2). Figures 2–4 show the proper
use of barriers on radiographic equip-
ment. As with other operatory equip-
ment, using a foot switch or a wrapped,
hand-held remote switch with the x-ray
unit can reduce contact and minimize
cross-contamination (Fig. 5 and 6).
Dental radiographic film should be
dispensed aseptically from a central sup-
ply area and placed in a disposable con-
tainer, such as a paper cup or plastic bag
(Fig. 7). Other items that should be dis-
pensed aseptically from a central supply
area include reusable film-holding devices
(which also should be packaged and ster-
ilized between patient use); cotton rolls
(to stabilize film placement); and paper
towels, which can remove excess saliva
from exposed films and protect work sur-
faces where film could be placed after ex-
posure. Tables 3–5 list proper infection
control practices before, during, and after
exposure and during processing. Table 6
lists infection control practices during
film processing.
Handling films with and
without barriers
Film barriers offer a simple method for
maintaining proper infection control
measures when using a daylight loader.
Tests have shown that film barriers, when
placed correctly, prevent the penetration
of fluids.34 Commercially available film
barriers such as ClinAsept (Eastman

266 General Dentistry www.agd.org


Fig. 9. Barrier-protected film, opened care-
fully and allowed to drop onto a paper towel
to prevent contamination.
Fig. 10. Technique for aseptically removing
a dental radiographic film from its barrier
and allowing it to fall into a paper cup.
Fig. 11. Using a surface barrier to cover
the bite guide and chin rest of a panoramic
machine.
Fig. 12. Digital sensor covered with a plastic
sheath and a latex finger cot.
Table 4. Infection control practices during film exposure.
The DHCW should touch as few surfaces as possible; those surfaces should be barrier-
protected.
Dry each film with a paper towel after taking it from the patient’s mouth to remove
excess saliva.
Place the film in a disposable container such as a paper cup or plastic bag before
transporting it to the processing area (Fig. 13).
Do not touch the disposable container while wearing contaminated gloves.
During exposures, film-holding devices should be transferred to a covered work sur-
face protected by a surface barrier.
If the DHCW must leave the work area during film exposure, gloves must be removed
and hands washed. Before resuming with film exposures, the hands should be washed
again and new gloves donned.
Table 5. Infection control practices after film exposure.
After use, reusable film-holding devices should be placed in an area designated for
contaminated instruments.
All disposable contaminated items (for example, cotton rolls, bitewing tabs, paper
towels, and surface barriers) should be discarded in accordance with local and state
environmental regulations; gloves should be worn when handling them.
The DHCW should unwrap all covered surfaces carefully while ensuring that the un-
derlying surface remains untouched with the contaminated gloves.
The gloves should be removed and hands washed once all contaminated items are re-
moved and disposed. At that point, the lead apron may be removed and the patient
dismissed from the x-ray exposure area.
Any uncovered areas that were contaminated during the procedure should be cleaned
and disinfected using an EPA-registered, hospital-grade, tuberculocidal disinfectant.
Because these disinfectants can be skin irritants, DHCWs should wear utility gloves
when using them. Remember that chemical germicides may affect the control panel’s
electrical connections, so avoid applying them too liberally.
Table 6. Infection control practices for film processing.
Exposed films should be transported to the processing area in a disposable container
such as a paper cup or plastic bag. The container should never be touched with con-
taminated, gloved hands.
Prior to taking the films to the processing area, the gloves should be removed, the
hands washed, the area cleaned up, and the patient dismissed.
The following items should be unit dosed in the processing area prior to starting the pro-
cessing procedure: gloves; paper towels; paper cups; and film mount or paper envelope.
The gloves, paper towels, and paper cups are necessary for film handling prior to processing.
A paper envelope or film mount is used to hold and store the film(s) after processing
and should be labeled with the patient’s name and date.
Kodak, Rochester, NY; 800/933-8031), cessing time. Alternatively, dental facili-
which may be purchased with the film in- ties can purchase film barriers separately
serted into the barrier, can protect the and insert the film into the barrier prior
film packets from contamination while to the radiographic procedure (Fig. 8).
also reducing both preparation and pro- Other options include using a finger cot
May-June 2003 267
 Table 7. Procedure for handling films with film barriers. as a barrier or heat-sealing plastic wrap
around the film. Film barriers should be
Place a paper towel on the work surface. opened carefully in a lighted area using
gloved hands. The film packet should be
Next to the paper towel, place the disposable container containing the films.
dropped onto a paper towel or into a
Don gloves. paper cup for transport to the processing
Remove one contaminated film from the container. area (Fig. 9 and 10); once the film packet
Open the film barrier, carefully avoiding contact with the film packet. is in the processing area, it may be
Allow the film packet to drop onto the paper towel. opened in the conventional manner us-
Dispose of the film barrier. ing ungloved, clean hands.
Tables 7 and 8 list the recommended
After all film barriers have been opened, dispose of the container.
steps when handling films with or with-
Remove gloves and wash hands. out film barriers.
Secure the door and turn out the darkroom lights (if applicable).
Unwrap and process the films, handling them by the film edges only. Daylight loaders
Label a film mount or paper envelope with the patient’s name and date, using it to Daylight loaders usually have cloth or rub-
hold the processed films. ber sleeves, cuffs, or flaps to allow access to
the chamber while minimizing light expo-
sure. These units present an additional
challenge when processing contaminated
film packets because of the potential for
Table 8. Recommended steps for handling cross-contamination in the access open-
films not protected by film barriers. ings of the chamber. Table 9 lists steps rec-
ommended for processing nonbarrier-
Place a paper towel on the work surface. protected films in an automatic film
Place the disposable container containing the films next to the paper towel. processor with a daylight loader.
Secure the door and turn out the darkroom lights (if applicable).
Panoramic/cephalometric
Don gloves.
imaging
Remove one contaminated film from the container. Because contamination from blood or
Open the film packet tab, slide out the lead foil backing and black paper, and discard saliva is highly unlikely during extraoral
the film packet wrapping. radiographic procedures, the infection
Rotate the lead foil away from the black paper and discard as per local/state regulations. control practices that should be followed
Open the black paper wrapping without touching the film and allow the film to drop are rather simple (see Table 10). The
onto the paper towel (Fig. 14). main infection control concern when
Discard the black paper wrapping. taking a panoramic radiograph is the bite
guide. This item can be handled in sever-
Discard the container after all film packets have been opened.
al ways, including barrier-protecting it
Remove gloves and wash hands. with a surface barrier (Fig. 11) or finger
Process films, handling them by their film edges. cot, using a disposable bite guide, or ster-
Label a film mount or paper envelope with the patient’s name and date and use it to ilizing a reusable bite guide between each
hold the processed films. patient use.
Any area touched by contaminated, gloved hands should be cleaned and disinfected.
Digital imaging
Digital radiography is becoming more
common in dentistry, as it is considered
to offer advantages such as reduced pa-
tient radiation exposure, faster imaging
display, elimination of film and dark-
room armamentarium, the ability to
transmit images electronically, ease of
image storage, and the ability to manipu-
late the images.37 For digital radiography,
the equipment located in the operatory
includes a receptor, central processing
Fig. 14. Technique for removing a dental unit (CPU), keyboard, monitor, mobile
radiographic film aseptically from its black cart, and possibly a printer. These items can
Fig. 13. Exposed film is placed in a paper wrapper and allowing it to drop onto a become contaminated with aerosols and
cup for transport. paper towel. spatter generated from dental procedures

268 General Dentistry www.agd.org

and should be protected.
The CPU should be barrier-protected
except for the air vent, to prevent overheat-
ing. A foot switch can minimize contact
with the CPU switches. A commercial
vinyl keyboard cover should be used to
protect the keyboard. The keyboard cov-
er then should be barrier-protected with
plastic wrap, which is changed between
patients. The monitor may be wrapped
in high-touch areas only; avoid covering
the air vents that cool the tube. A screen
shade will prevent aerosols from contam-
inating the monitor screen; if the screen
is visibly soiled, it should be cleaned and
disinfected with an intermediate-level
disinfectant. If a printer is used in the
operatory, it also should be barrier-pro-
tected with plastic wrap. Again, avoid
covering the air vents that prevent heat
buildup.
There are two basic types of receptors:
direct sensors, which are attached to the
computer monitor via a cable, and stor-
age phosphor plates, which resemble in-
traoral film but are reusable and
processed in a scanner. Both types of re-
ceptors can become contaminated during
image exposure and handling. Unfortu-
nately, neither receptor can be auto-
claved, so it is important to use effective
barrier techniques. Digital system manu-
facturers recommend plastic sheaths for
preventing cross-contamination.
Two recent studies have shown re-
duced rates of direct sensor cross-con-
tamination by augmenting the plastic
sheath provided by the manufacturer
with a latex finger cot (Fig. 12).38,39 Stor-
age phosphor plates require a barrier
provided by the manufacturer and
should be handled as described previous-
ly for intraoral films. There are no stan-
dardized infection control practices for
digital radiography at present, but new
technologies are being developed to facil-
itate infection control, including rubber
keyboards, keyless keyboards, and flat-
panel touchscreens.
Summary
Infection control has become a signifi-
cant part of dentistry. Dental employers
should ensure that their employees com-
ply with the current mandates of Stan-
dard/Universal Precautions. In addition,
all dental offices and clinics should devel-
op a written infection control plan that
describes specific practices to prevent the
Table 9. Steps for processing nonbarrier-protected films
in an automatic film processor having a daylight loader.
Place a paper towel on the surface inside the daylight loader compartment.
Place a paper cup and powder-free gloves in the daylight loader compartment.
Place the container with contaminated films next to the paper cup (Fig. 15).
Close the daylight loader lid and place hands through the sleeves.
Don gloves.
Remove one contaminated film from the container.
Open the film packet as described in Table 8.
Allow the film to drop onto the paper towel or processor film feed slot.
Dispose of the film packet contents in the empty paper cup.
After all film packets have been opened, remove gloves and place them in the paper cup.
Feed all unwrapped films into the processor, handling them only by their edges (Fig. 16).
Remove hands from daylight loader.
Wash hands.
Lift the lid of the daylight loader to remove all contents.
Label a film mount or paper envelope with the patient’s name and date, using it to
hold the processed films.
Table 10. Infection control practices
during extraoral radiographic procedures.
Prior to taking an extraoral radiograph, the DHCW should wash his or her hands.
The patient should rinse with a preprocedural mouthwash before the procedure. If
barriers are used, they should be placed before positioning the patient. After the pro-
cedure, ask the patient to remove the barrier on the bite guide (or the disposable bite
guide) and place it in the regular waste bin.
If this procedure is performed by the DHCW, he or she should don gloves before re-
moving the contaminated item. The gloves should be discarded and hands washed
prior to handling the film cassette.
For hygienic purposes, the patient chin rest, head-positioning guides, and handgrips can
be barrier-protected or cleaned after film exposure. Since patient secretions normally do
not contaminate extraoral cassettes, cassettes can be handled with ungloved hands.
No other infection control steps are necessary for processing.
Fig. 15. Unit dosing of a paper towel, Fig. 16. Proper method for handling films
powder-free gloves, and an empty paper as they are fed into the automatic processor.
cup. The paper cup with the contaminated
films also is placed inside the daylight loader
compartment.
May-June 2003 269
transmission of infectious diseases
through direct contact and cross-con-
tamination. The key to preventing cross-
contamination in dental radiology is to
practice proper asepsis to break the chain
of transmission of patient contaminants
(that is, blood and/or saliva) from the
oral cavity to surfaces and items used
and/or touched during the radiographic
procedure. Specific infection control
practices are recommended before, dur-
ing, and after film exposure and during
the processing of intraoral radiographs
to prevent cross-contamination. Infec-
tion control practices are changing con-
stantly and it is important that dental
staff members stay abreast of these
changes.
The infection control practices out-
lined here describe a simple, efficient
asepsis protocol for the entire dental staff
to follow during dental radiographic pro-
cedures to prevent cross-contamination.
There is no direct evidence suggesting
that the spread of oral microorganisms
during a radiographic procedure is a
major cause of disease transmission
between DHCWs and patients but the
possibility cannot be ignored. The poten-
tial for cross-contamination in dental ra-
diology is very high but using effective
infection control practices can reduce
this potential significantly, protecting
both patients and staff.
Disclaimer
The views expressed in this article are
those of the authors and do not reflect
the official policy of the Department of
Defense or other departments of the
United States Government.
Author Information
Col Bartoloni is Director, Professional
Services at the USAF Dental Investigation
Service, Naval Training Center, Great
Lakes, Illinois, where Col Charlton is Di-
rector, Materials Evaluation. Dr. Flint is a
Postdoctoral Fellow in Oral and Maxillo-
facial Radiology at the University of Texas
Health Science Center, San Antonio.
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