INFECTION CONTROL

Protecting the dental team from the patient.

Why Is Infection Control Important in Dentistry? Both patients and dental health care personnel (DHCP) can be exposed to pathogens Contact with blood, oral and respiratory secretions, and contaminated equipment occurs Proper procedures can prevent transmission of infections among patients and DHCP

 Microbial exposures in dental operatory involve both airborne contamination and digital contamination of surfaces.

Methods of Disease Transmission

Modes of Transmission
Direct Transmission Indirect Transmission Splash or Spatter Airborne Transmission Parenteral Transmission Bloodborne Transmission

Direct Transmission
Pathogens can be transferred by coming into direct contact with the infectious lesion or infected body fluids, including blood, saliva, semen, and vaginal secretions.

Indirect Transmission
The indirect transfer of organisms to a susceptible person can occur by handling contaminated instruments or touching contaminated surfaces.

Splash or Splatter
Diseases can be transmitted during dental procedures by splashing the mucosa or non intact skin with blood or bloodcontaminated saliva.

Airborne Transmission
Also known as droplet infection Spread of disease through droplets of moisture containing bacteria or viruses. Exists in the form of spatter, mist and aerosols
AEROSOLS consist of invisible particles ranging from 50 um to approximately 5 um that remain suspended in the air and breathed for hours MISTS consist of droplets estimated to approach or exceed 50 um SPATTER consists of particles larger than 50 um and are visible splashes

Parenteral Transmission
Parenteral means through the skin, as with cuts or punctures. Parenteral transmission of blood borne pathogens can occur through needle stick injuries, human bites, cuts abrasion, or any break in the skin.

Bloodborne Transmission
Occurs through direct or indirect contact with blood and other body fluids.

 Digital contamination of surfaces

Hands soiled with saliva that repeatedly contact operatory equipment and surfaces and return to the patients mouth during treatment

There are 3 potential modes of disease transmission:

From patient to dental personnel
Microorganisms from the patients mouth can be passed to the dental personnel through the following routes: 1. Direct contact most common route 2. Droplet infection 3. Indirect contact

Patient

DHCP

From Dental personnel to patient From patient to patient

DHCP
Patient

Patient
Patient

Infection control consists of those procedures and practices which will

most effectively result in the following:

Patient protection Personal protection Personnel protection

Infectious diseases
Infectious diseases are those which can be transmitted to others either by direct exposure to the causative organism or secondarily by contact with infected objects or surfaces. Infectious diseases of interest to dental operators are transmitted by:
BLOOD NASAL SECRETIONS SALIVA SPUTUM CONTACT WITH THE LESION CHILDHOOD DISEASES

Six components in the chain of infection control

Infectious agent
Pathogenic microorganisms or pathogens Viruses, bacteria, fungi, protozoa and rickettsia

Means of transmission
Direct contact Airborne transmission Blood transmission Ingestion Indirect contact

Reservoir
Location of the infectious agent Individual, equipment, food, water, animals or insects

Portal of entry
Allows the infectious agent to enter and potentially infect another person or a susceptible host Broken skin, mucous membrane, and systems of the body exposed to the external environment

Portal of exit
Doorway Body fluids, including excretions, secretions, skin cells, respiratory droplets, blood and saliva

Susceptible host
Individual is able to contract the pathogenic microorganism

Definition of terms
STERILIZATION destruction of all life forms, including spores DISINFECTANT chemical used to kill pathogenic microorganisms on an inanimate object such as a table top ANTISEPTIC chemical used to kill pathogenic microorganisms on a living organism such as the surface of the human body

ASEPTIC free of microorganisms; synonymous with sterile, i.e. the absence of life; SANITIZE to reduce microbial populations to a safe level as determined by public health standards CROSS-INFECTION infection passed from on person to another DECONTAMINATION to make as clean as possible, but not disinfected, nor sterile

 DISINFECTION destruction of most microorganisms, but not necessarily all, especially not highly resistant spore forms IMMUNOCOMPROMISED a reduction in a persons natural immunity due to disease processes IMMUNOSUPPRESSED a reduction in a persons natural immunity due to medication INFECTION presence of pathogens in the body following invasion by contaminated material SEPTIC contaminated or infected

Universal Precautions
ALL PATIENTS AND BLOOD CONTAMINATED FLUIDS ARE TREATED AS INFECTIOUS

Standard Precautions

Apply to all patients Integrate and expand Universal Precautions to include organisms spread by blood and also Body fluids, secretions, and
excretions except sweat, whether or not they contain blood Non-intact (broken) skin Mucous membranes

Elements of Standard Precautions

Hand washing Use of gloves, masks, eye protection, and gowns Patient care equipment Environmental surfaces Injury prevention

Hand Hygiene
Why Is Hand Hygiene Important?

Hands are the most common mode of pathogen transmission Reduce spread of antimicrobial resistance

Hands Need to be Cleaned When

Visibly dirty After touching contaminated objects with bare hands Before and after patient treatment (before glove placement and after glove removal)

Personal Protective Equipment

A major component of Standard Precautions Protects the skin and mucous membranes from exposure to infectious materials in spray or spatter Should be removed when leaving

Masks, Protective Eyewear, Face Shields

Wear a surgical mask and either eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth Change masks between patients Clean reusable face protection between patients; if visibly soiled, clean and disinfect

Protective Clothing

Wear gowns, lab coats, or uniforms that cover skin and personal clothing likely to become soiled with blood, saliva, or infectious material Change if visibly soiled Remove all barriers before leaving the work area

Gloves

Minimize the risk of health care personnel acquiring infections from patients Prevent microbial flora from being transmitted from health care personnel to patients Reduce contamination of the hands of health care personnel by microbial flora that can be transmitted from one patient to another Are not a substitute for handwashing!

Recommendations for Gloving

Wear gloves when contact with blood, saliva, and mucous membranes is possible Remove gloves after patient care Wear a new pair of gloves for each patient

Recommendations for Gloving

Remove gloves that are torn, cut or punctured

Do not wash, disinfect or sterilize gloves for reuse

INFECTION CONTROL MEASURES

Immunizations Medical history Handwashing Personal protective equipment

Protective clothing- laboratory gowns, surgical scrubs, Protective masks Protective eyewear- clear face shields, glasses with protective side shields Gloves

Surface barriers ( plastic bags, aluminum foil)

OPERATORY ASEPSIS

Surfaces typically protected with barriers

Headrest on dental chair Control buttons on dental chair Light handles Light switches Evacuator hoses and control Air-water syringes Dental unit control switches

Precleaning and Disinfection

Precleaning
Means to clean before disinfecting. Reducing the number of microorganisms present by physically removing debris. Regular soap and water maybe used for precleaning. Remember: if a surface is not clean, it cannot be disinfected.

Disinfection
Intended to kill disease-causing microorganisms that remain on the surface after precleaning.

Two-step procedure of disinfection:

Initial step: vigorous scrubbing of the surfaces to be disinfected and wiping them clean
Second step: wetting the surface with a disinfectant and leaving it wet for the time prescribed by the manufacturer

Two principles of disinfection

1. disinfection cannot occur until fresh disinfectant is reapplied to a thoroughly cleaned surface 2. disinfection does not sterilize

Classification of instruments and equipments

Critical instruments Are surgical and other instruments used to penetrate soft tissue or bone Forceps, scalpels, bone chisels, scalers, and burs Must be heat-sterilized before reuse. Semicritical instruments Are objects that come in contact with the oral tissues but do not penetrate soft tissue or bone. Plastic handled brushes, high volume evacuator tips and amalgam carriers, mouth mirrors Must be disinfected at high level if they cannot be sterilized. Noncritical instruments items that normally do not penetrate or contact mucous membranes, but that may be contaminated; require intermediate level disinfection; environmental surfaces such as chairs, benches, floor walls and supporting equipment of the dental unit that are not ordinarily touched during treatments

Rule: Don't disinfect anything you can sterilize!

Ideal Surface Disinfectants

Kills a broad spectrum of bacteria, has residual activity, minimal toxicity, and does not damage surfaces to be treated

Chemical classification of disinfectants

Level of Disinfection
High level

EPA Classification
High level of disinfectants with a relatively short contact time, and a sterilant when used with a prolonged contact time Hospital disinfectant with tuberculocidal activity

Use
Semicritical items that cannot tolerate heat sterilization

Intermediate level

Noncritical items that have been contaminated with blood or saliva

Low level

Nontuberculocidal

Surfaces not contamianted with blood

Types of disinfectants
Iodophors
EPA registered intermediate level hospital disinfectants with tuberculocidal action recommended for disinfecting surfaces that have been soiled with potentially infectious patient material Effective within 5 to 10 minutes Corrode or discolor metals

 Synthetic Phenol Compounds

Intermediate level hospital disinfectants with broad spectrum activity Used on metals, glass, rubber, or plastic Used as holding solution for instruments Leave a residual film on treated surfaces

 Sodium Hypochlorite
Commonly known as household bleach is a fast acting, economic, and broad spectrum intermediate-level disinfectant Disadvantage instability and need for daily preparation, strong odor and corrosive to some metals, destructive to fabrics, cause plastics chair covers to crack, irritating to the eyes and skin.

 Alcohol
Ethyl alcohol and isopropyl alcohol have been used as skin antiseptics and surface disinfectants Not effective in the presence of bioburden such as blood and saliva

 Chlorine dioxide
Used as effective, rapid-acting, environment surface disinfectant or as chemical sterilant Do not readily penetrate organic debris and must be used with a separate cleaner. It must be prepared fresh daily Used with good ventilation It is corrosive to aluminum containers

STERILIZATION
Four methods of sterilization
1.Steam pressure sterilization (autoclave) 2.Chemical vapor pressure sterilization (chemiclave) 3.Dry heat sterilization (dryclave) 4.Ethylene oxide sterilization

Steam pressure sterilization (autoclave) Involves heating water to generate steam, producing a moist heat that rapidly kills microorganisms Advantage: most rapid and effective method for sterilizing cloth surgical packs and towels Disadvantage: moisture may cause corrosion on some high-carbon steel instruments

Chemical vapor pressure sterilization (chemiclave) Similar to autoclaving, except a combination of chemicals is used instead of water to create a vapor for sterilization. Advantage: does not rust, dull, or corrode dry metal instruments, short cycle time, availability of a dry instrument after the cycle. Disadvantage: adequate ventilation is essential

Dry heat sterilization (dryclave) Operate by heating up air and transferring that heat from the air to the instruments. Requires higher temperatures than steam or chemical vapor sterilization Advantage: instruments will not rust if they are thoroughly dry before they are placed in the sterilizer

Ethylene oxide sterilization

Operates at low temperatures which is an advantage for plastic and rubber items that would melt in heat sterilizers Requires 4 to 12 hours for sterilization Ineffective on wet items