DR MARIA K SIDDIQUI

Infection Control
 Aim: To provide highest level of infection control possible
and practical that will ensure a safe environment for both
patient and clinician.
 Objectives:
 Elimination of cross contamination by breaking the chain
of infection.
 Reduction of available pathogenic microorganism to a
level at which normal resistance mechanisms of the body
may prevent infection.
 Application of universal precautions by treating each
patient as if all human blood and body fluids are known
to be infectious for HIV,HBV and other blood born
pathogens.
Guideline for Infection Control
 ADA and Center for disease control and prevention have
developed guidelines for infection control.
 All guidelines are based on concept of standard
precautions, previously called universal precautions.
 A parallel approach presented in 1987 called body
substance isolation which focuses on reducing
transmission of infection from any most body substance of
the patent to the health care work.
 The universal precautions emphasize on barrier
procedures, routine autoclaving of instruments and means
of handling potentially infectious material.
 In 2003 CDC guidelines combined body substance
isolation and universal precautions called Standard
infection control procedures.
OSHA and Dental Practice
 In USA OSHA(occupational safety and health
administration) is responsible for establishing standard for
safe and healthy working in almost all industries
 Blood-born pathogen standard came into effect in 1992.
 BP standard covers instrument sterilization and storage
handling of contaminated equipment, disposal of medical
waste. HBV vaccination to staff reporting needle stick
injuries, level of washing and storing laundry.
 The BP standard is a formidable document.
 Barriers for Patient and Clinician
Protection
 Immunization
 Management programs:
a) Recommended tests
Serologic test for herpes simplex virus I (HSV I)
antibodies to determine susceptibility to primary
HSV.
Annual tuberculin test
b) Written records: keep written records of
immunization, reimmunization and booster plan for
regular follow up.
 Clinical Attire:
 The wearing apparel of clinicians and their assistants is
vulnerable to contamination from splash, aerosol and
patient contact.
 Gown, scrub suit with solid closed fronts with out
pockets.
 Hair or head cover
 Face mask
 Face shields
 Proper syringe capping Techniques
 HIV / AIDS
 Acquired immunodeficiency syndrome is the end point of HIV
infection.
 Aids virus is a retrovirus.
 Aids is the final progressive process of immunological deficit
mediated by the virus.
 Pnuemocystis carinii pnuemonia is the most common
opportunistic infection.
 In severe HIV infection the CD 4+ T- cell count of 200/uL or
less.
 Modes of Transmission:
Sexual transmission
Infected mother to infant
Transfusion of infected blood
Intravenous drug use
Investigations in adults
 Detection of HIV antibody: enzyme-linked
immunosorbent assay (ELISA), Western blot.
 Assessment of viral load: detection of virus or viral antigen:
HIV RNA or branched DNA (bDNA) assay.
 FBC: anaemia, thrombocytopenia, lymphocytopenia with
reduced CD4 cell count.
 Raised ESR.
 Assessment of other infections: eg tuberculosis, hepatitis
B, cytomegalovirus (CMV), toxoplasma, syphilis, varicella.
 Screening for co-existing sexually transmitted diseases
(STDs).
 Baseline CXR and cervical smear.
 It may be appropriate to screen for glucose-6-phosphate
dehydrogenase (G6PD) deficiency in appropriate racial
groups.
 Diagnosis
 Is based on detecting anti-HIV antibodies in serum.
 Acute infection may be detected by the presence of P24
antigen or HIV RNA by polymerase chain reaction (PCR)
and precedes the appearance of IgM and IgG.
 A combination test checking for the presence of HIV
antibody and p24 antigen (the so-called 'fourth generation
test') is provided by hospital and is very accurate. It takes
about four weeks to get the result back.
Investigation in children
 Standard anti-HIV IgG antibody tests cannot be used
before 18 months of age, as maternal antibodies may
be detected.
 PCR and virus culture are the best investigations in
children born to infected mothers.
 38% of infected infants can be detected within the first
48 hours after birth, rising to 96% at four weeks .
Oral manifestations of HIV
 Principal signs of HIV
 Oral candidiasis
 Hairy leukoplakia
 Kaposi sarcoma
 Chronic Herpes Simplex
Oral Candidiasis
 Fungal infection.
 Usually present as a white plaque on the palate.
 Plaque can be sore and very common among HIV
infected individuals.
Candidiasis
Oral Hairy Leukoplakia
 Lesion commonly appear on lateral surface of tongue.
 Wide variation in size, severity and characteristics of
lesion.
 Condition is highly predictive of future development
of aids.
 It is caused by Epstein-Barr virus (EBV)
Kaposi Sarcoma
 Diagnostic for aids.
 Found in 28%-34% of aids patients.
 Palate is the most common intraoral site.

 Most common finding in case of pediatric aids.

 Oral candidiasis
 Parotid gland enlargement
 Herpetic infection
Kaposi Sarcoma
Oral Hairy Leukoplakia
Oral Hairy Leukoplakia
Hepatitis B and C
 Hepatitis is more prevalent than HIV.
 In poor countries 8%-10% of the total population
is chronically infected.
 In poor countries liver cancer is a result of chronic
HBV infection and among top 3 causes of death in
men.
 1% population is chronically infected in high
income countries.
 HBV is primarily the disease of adults in united
states. New infections are common in the age 20-
29.
 On the other hand in poor countries HBV is more
common in children.
Transmission of HBV and HCV
 HBV and HCV are transmitted by contact with
infected blood.
 Primary transmission routes:
Sexual contact both homosexual and heterosexual
and unprotected sex.
Sharing of infected needles/ Needle stick injury
Perinatal transmission to an infant born to an infected
mother.
Needle Stick Injury
Single Hand Needle
Capping Technique
 Fatality rate from HBV is low (0.5%-1%) infected
person recover completely in due course.
 HBV carriers are at risk of long term sequelae such as
chronic liver disease, liver cirrhosis and liver cancer.
 Infected young children (30%-90%) can develop
chronic infection. In case of infected adults 2%-10%
can develop chronic infections.
 Chronic infection can be asymptomatic but 15%-25%
of this group can die prematurely from cirrhosis or
liver cancer.
 Signs and symptoms of hepatitis B and C are:
 Fatigue
 Abdominal pain
 Loss of appetite
 Intermittent nausea
 Vomiting
 Jaundice

 Health care workers are at higher risk of than general

population because they are likely contact with
carriers.
 Blood and serous fluids have highest conc of HBV in
infected person; concentration in saliva in little lower.
 Carriers of HBV can easily transmit the diseases to any
one to whom they come in contact in day to day life.
 HBV virus can also be transmitted by percutaneous
and non percutanoeous routes.
 Risk of contracting HBV is 3-10 times greater for
dentist than for general population.
 Types of hepatitis identified are A,B,C,D and E.
 HCV infection has an insidious onset and can easily be
missed at early stages like HBV.
 Majority of HCV infected person show no symptoms
however some patients do show symptoms similar to
HBV.
 No vaccine has yet been develop for HCV.
 The barrier precautions and sterilization procedures
for preventing HCV are same as HBV.
 For HBV immunization through a series of 3 injection
over 6 months will be required.
 Vaccination specific for HBV does not protect against
HCV.
 Hepatitis C Testing
 Also known as: Hepatitis C Antibody; Anti-HCV;
HCV-PCR; HCV-RNA; Hepatitis C Viral Load
 Formal name: Viral Hepatitis C Antibody Screen;
Viral Hepatitis C RNA by PCR; Hepatitis C Virus
Genotype
Table 1. Serological tests that constitute the diagnostic panel for HBV

Hepatitis B surface Active infection (acute

HBsAg
antigen or chronic)

Hepatitis B surface Immunity (vaccination

Anti-HBs
antibody or infection)

Hepatitis B core Infection (past or

Anti-HBc
antibody current)
HIV issues in Dental Practice and
Dental education
 The rights of infected Dentist to practice.
 On the other hand,
 Willingness to treat HIV infected patient is an issue , which
should deal with vigorously.
 According to ADA code of ethics refusal to treat HIV
patient is unethical.
 However it is also illegal, 1.The risk of cross infection
despite standard precaution, 2. Many Dentist already have
treated HIV infected without knowing it.
 Same issue in Dental education 1. HIV+ student admitted
to Dental school or not 2. What if becomes HIV+ during
course.
Dental Unit Water lines
 An issue related to water line infection is back flow.
 Cross connection(contaminated materials entering
public water supply) is possible through the high
speed hand piece, air and water syringe, however risk
is extremely low.
 Back flow relates to the chance of HIV, HCV, HBV
infections but possibility is close to zero
 The use of self contained water systems in the dental
office not connected to public water supply is a
recommended measure to reduce any possible risk
Instruments
 Critical instruments:
 Instruments used to penetrated soft tissue or bone.
 Such as forceps, blade, scalpel, chisel, Scalers.
 Should be sterilized after each use.
 Semi critical instruments:
 Instruments that do not penetrate soft tissue or bone but
contact oral tissues.
 Such as mouth mirror, condenser etc.
 Should be sterilized after each use or high level
disinfection.
 Non critical instruments:
 Instruments or devices such as external components of
ray heads that come in contact with intact skin. These
instruments have low risk of transmitting infection.
Definitions
 Cleaning
 process which physically removes contamination but
does not necessarily destroy micro-organisms
 prerequisite before decontamination by disinfection or
sterilisation of instruments
 organic material prevents contact with microbes,
inactivates disinfectants
 Disinfection
 using an agent that destroys germs or other harmful
microbes or inactivates them, usually referred to
chemicals that kill the growing forms (vegetative forms)
but not the resistant spores of bacteria
 Antisepsis
 destruction of pathogenic microorganisms existing in
their vegetative state on living tissue
 Sterilization
 any process, physical or chemical, that will destroy all
forms of life, including bacterial, fungi, spores, and
viruses
 Sterilization
 Process by which an article surface or medium is freed to
all microorganism either in vegetative or spore form.
 Moist Heat: steam under pressure
 Dry heat
 Chemical vapor
 Ethylene Oxide
 Choice of sterilization method depends on practical issues
such as ease of use or material compatibility
 Cleaning of objects needed before attempt at sterilization
Autoclave (Steam under pressure)
 Destruction of microorganism by heat takes place as a
result of inactivation of cellular proteins or enzymes.
Moist heat causes coagulation of proteins.
 Temp: 121 C at 15 pounds pressure for 15 mins.
 Use 30 min for heavy load of to ensure penetration.
 Advantage:
 All microorganisms, spores, and viruses are destroyed
quickly and efficiently.
 Economical
 Disadvantage:
 Corrosion of carbon steel instruments
 Materials to be sterilized should be wrapped in paper
and steam permeable plastic.

Dry Heat
 Action of dry heat is oxidation.
 Temp 160 C (320 F).
 Time: 2 hours or 1 hour for 170 C
 Advantage:
 No corrosion
 Well suited for sharp instruments.
 Use full for material that cannot stand stem under
pressure.
 Disadvantage:
 High temperature is critical for plastic materials.
Autoclave
Chemical Vapor Sterilization
 A combination of alcohols, formaldehyde, ketone,
water and acetone heated under pressure produces a
gas that is effective as strigling agents.
 Time / Temp: 20 min 127 o C -132 o C
 Pressure: 20-40 pounds
 Advantage:
 Rust free operation for carbon steel instruments.
 Less time consuming
Sterilization for Heat sensitive Instruments
 Cold sterilization (Liquid chemicals The use of
chemicals classified as "sterilants)
 10 hour of exposure to chemical liquid agent.
 This sterilization is followed by aseptic rinsing with
sterile water, drying and if the instrument is not used
immediately, place in a sterile container.
Physical Methods
 Filtration
 Used on fluids and on air supplies
 Gamma-Irradiation
 Used on disposable plastics, e.g. in sealed packs
 Only in specialised centres
Mercury Safety
 Dental amalgam contains elemental mercury. It
releases low levels of mercury vapor that can be
inhaled. High levels of mercury vapor exposure are
associated with adverse effects in the brain and the
kidneys.
 Based on this evidence, FDA considers dental
amalgam fillings safe for adults and children ages 6
and above.
 Research has not shown any health effects from
amalgam fillings in pregnant women. However,
mercury can cross the placenta. Women should not get
amalgam fillings during pregnancy. Dentists can
suggest other materials for any pregnant woman who
needs a cavity filled.
 Occupational exposure is completely preventable with
the implementation of proper mercury hygiene
practices.
 There is no evidence in the scientific literature that the
minute amounts of mercury vapor that may be
released from amalgam restorations pose a health
threat. Allergic reactions to mercury and other
constituents of amalgam have been documented, but
are exceedingly rare.
 Some individuals have an allergy or sensitivity to
mercury or the other components of dental amalgam
(such as silver, copper, or tin). Dental amalgam might
cause these individuals to develop oral lesions or other
contact reactions.
Alternative to Amalgam
 Composite resin filling
 Glass ionomer filling
 Gold fillings
Mercury Hygiene Guidelines

 The ADA classifies amalgam scrap in the following

manner:
 Non-contact amalgam (scrap) is excess mix
leftover at the end of a dental procedure. Many
recyclers will buy this clean scrap.
 Contact amalgam is amalgam that has been in
contact with the patient. Examples are extracted
teeth with amalgam restorations, carving scrap
collected at chair side, and amalgam captured by
chair side traps, filters, or screens.
 Chair side traps capture amalgam waste during
amalgam placement or removal procedures (traps from
dental units dedicated strictly to hygiene may be placed
in the regular garbage).
 Vacuum pump filters or traps contain amalgam sludge
and water. Some recyclers will accept whole filters, while
others will require special handling of this material.
 Amalgam sludge is the mixture of liquid and solid
material collected within vacuum pump filters or other
amalgam capture devices.
 Empty amalgam capsules are the individually dosed
containers left over after mixing pre capsulated dental
amalgam.
 The use of disposable pre capsulated alloys eliminates
many potential sources of mercury vapor and minimizes
the possibility of accidental spillage.
 The following items should be considered when
establishing an effective mercury control program:
 Use only precapsulated alloy. If, for some reason,
elemental mercury must be stored, store it in
unbreakable, tightly sealed containers on stable surfaces.
 Perform all operations involving mercury over an area
that has an impervious and suitable lipped surface so as
to confine and facilitate recovery of spilled mercury or
amalgam. Whenever possible, perform these operations
over a tray.
 Clean up any spilled mercury immediately.
 Use a no-touch technique for handling amalgam. If
contact is made with mercury, the area affected should be
washed with soap and water to reduce the time that the
microscopic particles cling to the skin.
 Use tightly closed disposable capsules during
amalgamation. Loss of mercury during trituration can be
detected by wrapping adhesive tape around test capsules
prior to the mechanical mixing. If the capsules are tight
and no mercury is thrown out, the adhesive tape will be
clean after trituration.
 Place non-contact, scrap amalgam in wide-mouthed,
airtight container that is marked “Non-contact Amalgam
Waste for Recycling.” Make sure the container lid is well
sealed.
 Stock amalgam capsules in a variety of sizes. After
mixing amalgam, place the empty capsules in a wide-
mouthed, airtight container that is marked “Amalgam
Capsule Waste for Recycling.” Capsules that cannot be
emptied should likewise be placed in a wide-mouthed,
airtight container that is marked “Amalgam Capsule
Waste for Recycling.” Make sure the container lid is well
sealed. When the container is full, send it to a recycler.
 Salvage contact amalgam pieces from restorations after
removal. Store and label contact amalgam waste
separately from non-contact waste. Recycle the contact
amalgam waste according to instructions provided by
your recycler.
 Recycle amalgam scraps through refiners who are
properly licensed by the Environmental Protection
Agency. The ADA’s Directory of Dental Waste Recyclers
can be found at:
http://www.ada.org/prof/resources/topics/topics_amalre
cyclers.pdf
 Work in well-ventilated spaces that have rapid fresh air
exchanges. If air conditioning is present, replace
filters often.
 Avoid carpeting dental operatories, as
decontamination is not possible. The use of a
continuous, seamless sheet of flooring that extends up
the walls at least 10 centimeters is recommended. If
the operatory is already carpeted, do all mercury
transfers in another area. Carpeting and floor cracks
serve as collectors for spilled mercury.
 Eliminate the use of mercury-containing solutions.
 Avoid heating mercury or amalgam. Keep it away from
direct sunlight and other heat sources.
 Water spray and high-volume evacuation should be used
when removing old amalgam restorations or finishing
new ones. A fiber-type mask should also be worn when
cutting out old amalgams. Evacuation systems should
have traps or filters, which should be checked and cleaned
or replaced periodically.
 Use conventional dental amalgam compacting
procedures, manual and mechanical, but avoid the use
of ultrasonic amalgam condensers.
 Expressing excess mercury from amalgam must be
avoided. Disposable pre-capsulated alloys should be
used.
 Amalgamator arms and capsules should be covered
during trituration.
 Contaminated instruments should be thoroughly
cleaned before sterilization.
 Disposable items contaminated with mercury should
be discarded in properly sealed containers.
 Have periodic mercury vapor level determinations
made in operatories.
 Office Monitoring
 Periodic monitoring can be a valuable adjunct for
assessing the effectiveness of mercury hygiene
procedures in the dental office. The dental office
should be monitored for mercury vapor once every two
years, or more frequently if contamination is
suspected.
 In the event of serious contamination, such as a spill,
the office should be monitored until a safe threshold is
reached. Arrangements for monitoring can usually be
accomplished by contacting the local Office of
Environmental Health.
 Medical Surveillance
 Biologic monitoring through periodic urine analysis
for mercury is a recommended method for assessing
the exposure of dental office personnel. These
periodic checkups are excellent as an indirect
evaluation of the effectiveness of mercury hygiene in
an office.
 The maximum allowable mercury level is 0.15
milligrams/liter (150 micrograms/liter) according to
OSHA, and the normal level generally is approximately
0.015 milligrams/liter (15 micrograms/liter).
 Cleanup of Spilled Mercury
 Any spilled mercury should be cleaned up immediately.
Effective techniques for cleanup of any spilled mercury
include using a wash-bottle trap connected to a low-
volume aspirator of the dental unit for removing visible
droplets of mercury. The trap bottle connection should
keep the mercury in the bottle and not let it be sucked into
the dental unit. Other devices for recovering mercury
include handheld pumps, aspirator bulbs, or plastic
syringes. Sponges are generally not effective for mercury
cleanup. Adhesive tape, tin foil, or a fresh mix of dental
amalgam can remove droplets of mercury if undisturbed.
Reagents that combine with mercury may facilitate
cleanup. Commercially available spill cleanup kits that
contain a combination of these devices and materials have
proved useful. A household vacuum cleaner should not be
used on spilled mercury or on contaminated floors.