Dr Sara Sarraj

Both patients and dental personnel can be exposed to pathogens Contact with blood, oral and respiratory secretions, and contaminated equipment occurs Proper procedures can prevent transmission of infections to patients and dental Team.

Pathogen:sufficient virulence & adequate numbers Source:fertile soil for germ growth Mode: pathway of transmission from source to host Entry: Portal of the pathogen Susceptible host: Host with deficient immune system The pathway of disease transmission between people is referred to as the chain of infection

Direct transmission primary exposure

Needle-stick and sharps injuries Injury from an instrument during a procedure Spray or debris entering the eye Bacterial aerosol and splatter during a procedure Unprotected skin

Indirect transmission secondary exposure

Contaminated instruments Contaminated surfaces and equipment Bacterial aerosol

Invisible particles 5nm-50nm Suspended in the air and breathed for hours May carry respiratory infectious agents No evidence for transmission of blood borne infection such as HBV,HIV

Almost 50nm Become visible in a beam of light Settled after 5-15 minutes Mist+aerosol can transmit active tuberclosis

Particles>50nm,visible splashes, 3feet from patient mouth,therefore can cover face and garment of attending dental team Source of blood borne pathogens

Dentistry as it may have been practiced in the past. Rotary instrumentation can expose personnel to heavy spatter of more than 50-mm particles and mists. Aerosol particles of less than 5 mm remain suspended and can reach the alveoli if not stopped by a barrier. Air purification is a growing concern.

Assume all patients are potentially infectious Infection control policies are determined by the procedure, not the patient

Handwashing Using personal protective equipment Handling contaminated materials/equipment to prevent cross contamination Cleaning/disinfecting environmental surfaces Using engineering/work practice controls Respiratory hygiene/cough etiquette Safe injection practices

Used with standard precautions to interrupt the spread of certain pathogens Three types
Airborne (TB) Droplet (>5 microns) (Influenza) Contact (Herpes)

Varicella Measles Mumps Rubella Influenza Hepatitis B

Policies should encourage personnel to seek care & report their illnesses

Standard Precautions Engineering Controls Work Practice Controls Post-exposure Management and Prophylaxis

3 dose vaccine Check for antibodies 1-2 months after third dose Revaccinate DT(Dental Team) who do not develop adequate antibody response Booster doses of vaccine and periodic serologic testing to monitor antibody concentration after completion of the vaccine series are not recommended for vaccine responders

Safe Effective Long lasting

Controls that isolate or remove the bloodborne pathogens hazard from the workplace Commonly used in combination with work practice controls and Personal protective equipment (PPE)to prevent exposure Follow local policy

Practices incorporated into the everyday work routine that reduce the likelihood of exposure by altering the manner in which a task is performed

Handling Syringes

Specify: eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood/OPIM (including saliva in dental settings) resulting from performance duties Establish procedure for reporting and evaluating exposure incident

Mucous membrane contact Splash to the eyes, nose or mouth

Percutaneous inoculation Misuse of sharps (broken glass, needles, scalpels, dental bur, knife)

Exposure to broken/damaged skin Risk increases if contact involves a large area of broken/damaged skin or if contact is prolonged

* Risk increases with high titer levels in the source

Source

Risk (%)

HIV Hepatitis C Hepatitis B

0.3 1.8 3.0

Clean wounds with soap and water Flush mucous membranes with water No evidence of benefit for:
application of antiseptics or disinfectants squeezing (milking) puncture sites

Avoid use of bleach and other agents caustic to skin

Date and time of exposure Procedure detailswhat, where, how, with what device Exposure details...route, body substance involved, volume/duration of contact Information about source person Information about the exposed person Exposure management details

Immediate evaluation & follow-up completed by a qualified health-care professional After each incident review circumstances surrounding the injury & the post-exposure plan Provide training to implement changes as needed

Report all needle stick and sharps-related injuries promptly to ensure that you receive appropriate follow-up care. Tell your employer about any sharps hazards you observe. Participate in training related to infection prevention. Get a Hepatitis B vaccination.

Skin: Do not squeeze(Milk) the wound to bleed it, do not put the pricked finger in mouth. Wash with soap &water, dont scrub, no antiseptics or skin washes (bleach, chlorine, alcohol, betadine). Eye: wash with water/ normal saline/ dont remove contact lens immediately if wearing, no soap or disinfectant. Mouth: spit fluid immediately, repeatedly rinse the mouth with water and spit / no soap/ disinfectant.

Evaluation must be made rapidly so as to start treatment as soon as possible-ideally within 2hours but certainly within 72 hours of exposure. However all exposed cases dont require prophylactic treatment. Factors determining the requirement of( post exposure prophylactic)PEPNature/Severity of exposure and risk of transmission HIV status of the source of exposure HIV status of the exposed individual

HBV vaccination is recommended for all healthcare workers (unless they are immune because of previous exposure). HBV vaccine has proven to be highly effective in preventing infection in workers exposed to HBV. However, no vaccine exists to prevent HCV or HIV infection.

Eliminate or reduce the use of needles and other sharps Use devices with safety features to isolate sharps Use safer practices to minimize risk for remaining hazards

1.When hands are visibly contaminated 2.Before and after treating each patient (e.g., before glove placement and after glove removal) 3.After barehanded touching of Lifeless objects likely to be contaminated by blood or saliva 4.Before re-gloving ,after removing gloves that are torn, cut, or punctured 5.Before leaving the dental operatory, dental laboratory, or instrument processing area

When hands are visibly dirty, contaminated, or soiled non-antimicrobial or antimicrobial soap & water (rub hands together for a minimum of 15 seconds) use of liquid soap (vs. bar soap) and handsfree dispensing controls is preferable

If hands are not visibly soiled non-antimicrobial or antimicrobial soap & water (rub hands together for a minimum of 15 seconds) or alcohol-based hand rub (rub hands until dry)

Before an oral surgical procedure: antimicrobial soap and water; scrub hands and forearms for length of time recommended by manufacturer (usually 2-6 minutes) or alcohol-based hand rub with persistent activity: before applying, pre-wash hands & forearms with non-antimicrobial soap; follow manufacturer recommendations

Keep fingernails short with smooth, filed edges to allow thorough cleaning and to prevent glove tears

Protects the skin & mucous membranes of the eyes, nose, and mouth from exposure to blood or OPIM Use of PPE is dictated by the exposure risk, not the patient

Masks and Protective Eyewear

1.Wear a surgical mask and protective eyewear with solid side shields to protect mucous membranes of the eyes, nose, & mouth 2.Change masks between patients, or during treatment if it becomes wet

A face shield may substitute for protective eyewear,but not masks Clean protective eyewear with soap & water or if visibly soiled, clean & disinfect between patients

Wear long-sleeved reusable or disposable gowns, clinic jackets, or lab coats to protect skin of the forearms and clothing likely to be soiled with blood, saliva, or OPIM Change immediately if visibly soiled

Other potentionaly infectious materials (OPIM)

Clinical Gowns

1. The following human body fluids: Cerebrospinal fluid (fluid surrounding the brain and spinal cord) Synovial fluid (fluid surrounding bone joints) Pleural fluid Pericardial fluid Peritoneal fluid Amniotic fluid Saliva in dental procedures Any body fluid that is visibly contaminated with blood All body fluids in situations where it is difficult or impossible to differentiate between body fluids 2. Any unfixed tissue or organ (other than intact skin) from a human, or nonhuman primate (living or dead). 3. HIV-containing cell or tissue cultures, organ cultures, and HIV or HBVcontaining culture medium or other solutions, and blood, organs or other tissues from experimental animals infected with HIV or HBV. 4. Any pathogenic microorganism 5. Human cell lines

Long-sleeved protective clothing is indicated with Use of handpieces Sonic/ultrasonic scaling Manipulation using sharp cutting instruments (e.g., perio surgeries, prophies) Spraying air and water into a patients mouth Oral surgical procedures Manual instrument cleaning

Wear when potential exists for contacting blood, saliva, OPIM, or mucous membranes Gloves DO NOT replace the need for hand hygiene Wash hands before donning gloves and upon glove removal

Vinyl, nitrile, or latex examination gloves must be worn when treating nonsurgical patients

Do not wash gloves before use or for reuse Remove gloves that are cut, torn, or punctured

Sterile disposable gloves must be worn during all surgical procedures

PPE/Laundry
Remove all PPE before leaving the work area Do not store contaminated clothing or PPE in lockers or offices Place contaminated laundry in an appropriately labeled container

Instrument Processing Cleaning

minimize exposure potential Use carrying containers to transport contaminated instruments from the operatory to the instrument processing area

Instrument Processing Cleaning

Wear puncture- and chemicalresistant heavy duty utility gloves for instrument cleaning & decontamination procedures Wear a mask, protective eyewear, and long-sleeved protective clothing when splashing/spraying is expected during cleaning

Clean it First
Clean all visible blood and other contamination from dental instruments and devices before sterilization procedures
Ultrasonic Cleaner

Automated equipment is preferable to manual hand scrubbing If hand scrubbing is unavoidable, use work practice controls (e.g., long handled brush) & PPE

VS

Before heat sterilization, inspect instruments for cleanliness Wrap or place in packages to maintain sterility during storage

Use FDA-cleared medical devices

Steam autoclave Dry Heat Unsaturated Chemical Vapor

Do not overload the sterilizer Allow packages to dry in the sterilizer before handling

Mecahnical Chemical Biological

for monitoring sterilization include assessing the cycle time, temperature, and pressure of sterilization equipment by observing the gauges or displays on the sterilizer. Some tabletop sterilizers have recording devices that print out these parameters. Correct readings do not ensure sterilization, but incorrect readings could be the first indication that a problem has occurred with the sterilization cycle.

Internal and external, use sensitive chemicals to assess physical conditions such as temperature during the sterilization process. Chemical indicators such as heat sensitive tape change color rapidly when a given parameter is reached. An internal chemical indicator should be placed in every sterilization package to ensure the sterilization agent has penetrated the packaging material and actually reached the instruments inside. An external indicator should be used when the internal indicator cannot be seen from outside the package. Single-parameter internal indicators provide information on only one sterilization parameter and are available for steam, dry heat, and unsaturated chemical vapor. Multiparameter internal indicators measure 23 parameters and can provide a more reliable indication that sterilization conditions have been met. Multi-parameter internal indicators are only available for steam sterilizers (i.e., autoclaves). Refer to manufacturer instructions for proper use and placement of chemical indicators.

Indicator test results are shown immediately after the sterilization cycle is complete and could provide an early indication of a problem and where the problem occurred in the process. If the internal or external indicator suggests inadequate processing, the item that has been processed should not be used. Because chemical indicators do not prove sterilization has been achieved, a biological indicator (i.e., spore test) is required.

are the most accepted means of monitoring the sterilization process because they directly determine whether the most resistant microorganisms (e.g., Geobacillus or Bacillus species) are present rather than merely determine whether the physical and chemical conditions necessary for sterilization are met. Because spores used in BIs are more resistant and present in greater numbers than are the common microbial contaminants found on patient care equipment, an inactivated BI indicates that other potential pathogens in the load have also been killed.

Use an internal chemical indicator in every package. If the internal indicator is not visible from the outside, then use an external indicator Inspect indicator(s) after sterilization & at time of use

Use biological indicators (spore tests) at least weekly

Autoclave/chemiclave Geobacillus stearothermophilus Dry heat Bacillus atrophaeus

Whenever a new type of packaging material or tray is used. After training new sterilization personnel. After a sterilizer has been repaired. After any change in the sterilizer loading procedures.

Expiration date

package and its contents remain sterile until some event (e.g., the packaging becomes wet or torn) causes the item(s) to become contaminated

A surface contaminated from patient materials either by direct spray or spatter generated during dental procedures or by contact with DTs gloved hands

Use surface barriers to protect clinical contact surfaces, especially those that are difficult to clean Change barriers between patients

Clean and disinfect clinical contact surfaces that are not barrier-protected using an EPA-registered intermediate level (tuberculocidal) disinfectant after each patient

Clean housekeeping surfaces on a routine basis depending on nature of surface and contamination & when visibly soiled

Solid waste that is soaked or saturated with blood or saliva (e.g., gauze saturated with blood following surgery) Items that are caked with dried blood or OPIM capable of releasing these materials during handling
Extracted teeth Surgically removed hard & soft tissues Contaminated sharp items

Use water that meets standards set by the EPA for drinking water (fewer than 500 CFU/mL of heterotrophic water bacteria) for nonsurgical dental treatment output water

 Allows daily draining and air purging if indicated Allows application of periodic &/or continuous chemical germicides

Benefits

Water Bottle

Between patients, discharge water and air for a minimum of 20-30 seconds from any dental device connected to the dental water system that enters the patients mouth (e.g., handpieces, ultrasonic scalers, air/water syringe)

In-office testing with self-contained test kits Water laboratory testing using Method 9215 Test each unit quarterly or according to manufacturer instructions

Screen all patients for latex allergy Develop policies & procedures for evaluation, diagnosis, and management of DT with suspected or known occupational contact dermatitis Obtain a definitive diagnosis by a qualified health-care professional (allergist, dermatologist) for any DT with suspected latex allergy Have emergency treatment kits with latex-free products available

Clean & heat sterilize all headpieces and other intraoral instruments that can be removed from the air and waterlines of the dental unit between patients

Standard precautions Hand hygiene Personal protective equipment Clean and intermediatelevel disinfect all laboratory items before entering the dental lab Heat sterilize any items used intra orally or on contaminated appliances

PROVIDER

DENTAL LAB

Standard Precautions Hand hygiene PPE (gloves at a minimum) Clean & disinfect equipment or barrier-protect Heat sterilize accessories (film holding devices)

Transport and handle exposed radiographs in an aseptic manner to prevent contamination of developing equipment

Equipment difficult, if not impossible, to clean and disinfect Barrier-protect clinical contact surfaces

Barriers do not always protect the item from potential contamination Presently, these items are not heat-tolerant At a minimum barrier protect and clean & disinfect with an intermediate level disinfectant after barrier removal

During transport, place biopsy specimens in a sturdy, leakproof container labeled with the biohazard symbol
Leakproof Container

Biopsy

Regulated medical waste (unless returned to the patient) Do not dispose extracted teeth containing amalgam in regulated medical waste intended for incineration

Assess all patients for history of tuberculosis Most common symptom persistent/ productive cough Defer elective dental treatment until noninfectious

If patient must be treated: Separate from other patients (have them wear a mask) Refer to area/facility with proper air handling Staff to wear fittested N-95 mask

Incision, excision, or reflection of tissue that exposes normally sterile areas of the oral cavity Examples include: biopsy, periodontal surgery, implant surgery, apical surgery, & surgical extractions of teeth

Sterile irrigating solutions

Surgical hand antisepsis

Sterile surgeons gloves

Conventional dental units cannot reliably deliver sterile water even with an independent water reservoir Use a sterile irrigating syringe, sterile singleuse disposable tubing, sterilizable tubing or sterile water delivery systems

Reduce the level of oral microorganisms in aerosols & spatter. and Improves healing. May be most useful before procedures using a prophy cup or ultrasonic scaler or before surgical procedures

Use single-use devices for one patient only and dispose of appropriately Do not clean & sterilize for reuse

Effective infection-control strategies are designed to prevent disease transmission & must occur as routine components of practice. Proper procedures can prevent transmission of infections to patients and DT.

Ounce of prevention is better than pounds of cure

Think prevention

Exam at 11 am Saturday
10H 3&4 NB66