GUIDE TO INFECTION PREVENTION FOR DENTAL HEALTH CARE SETTINGS

Why Is Infection Control Why Is Infection Control Important Important in Dentistryin Dentistry??

Both patients and dental health care Both patients and dental health care personnel (DHCP) can be exposed to personnel (DHCP) can be exposed to pathogenspathogens

Contact with blood, oral and respiratory Contact with blood, oral and respiratory secretions, and contaminated equipment secretions, and contaminated equipment occursoccurs

Proper procedures can prevent Proper procedures can prevent transmission of infections among patients transmission of infections among patients and DHCPand DHCP

Infection prevention and occupational health

program A. Education and training of

faculty staff, interns and students.

B. Immunization Programs C. Illness and work restriction D. Exposure & Infection

prevention procedures (Standard Precautions)

B. Immunization Programs

Hepatitis B vaccination : Three-dose schedule administered intramuscularly (IM) in the deltoid; second dose administered 1 month after first dose; third dose administered 4 months after second.

Testing for anti- HBs 1–2 months after completion of the 3-dose vaccination

If anti-HBs <10 mIU/mL) → complete a second 3-dose vaccine series or be evaluated to determine if they are HBsAg-positive.

If no antibody response occurs after the second series, testing for HBsAg should be performed.

Non-responders to vaccination who are HBsAg-negative should be considered susceptible to HBV infection.

D. Exposure & Infection prevention procedures (Standard

Precautions)The Foundation of the Exposure Control

Plan is the use of Standard Precautions to prevent the transmission of bloodborne and other diseases from healthcare workers to patients and vice versa.

Medical histories and examinations cannot reliably identify all infected patients. Therefore all body fluids (with the exception of sweat) of all patients should be considered infectious.

Standard Precautionsbasic safety measures that must be

used for all patients. They include the use of appropriate barriers such as gloves, masks, and eye

glasses to prevent skin and mucous membrane exposure

when contact with blood, saliva or OPIM (other possibly infectious

material) is anticipated.

Objectives of Objectives of Standard Precautions

[a} Reduce the number of pathogens so that normal resistance can prevent infections

[b] Break the cycle of infection and eliminate cross-contamination,

[c] Protect all patients and personnel from infection

Modes of Transmission Direct contact with blood or body Direct contact with blood or body

fluidsfluids Indirect contact with a Indirect contact with a

contaminated instrument or surfacecontaminated instrument or surface Contact of mucosa of the eyes, nose, Contact of mucosa of the eyes, nose,

or mouth with droplets or spatteror mouth with droplets or spatter Inhalation of airborne Inhalation of airborne

microorganismsmicroorganisms

Exposure DeterminationAnyone who participates in any of the following tasks, even on a

sporadic basis, should follow standard precautions, receive training, and receive the HBV vaccine.

Performing clinical or laboratory dental procedures

Assisting in a dental procedure Cleaning and/or sterilizing contaminated

equipment Handling potentially contaminated laundry Scrubbing contaminated counter tops and other

environmental surfaces Disinfecting impressions Exposing radiographs Flushing water lines in the dental unit

Hand hygiene & Hand Hand hygiene & Hand carecare

You MUST: Put on mask and glasses before

washing hands. Remove all jewelry (including

watches) from hands and wrists. All fingernails must be kept short and never put false nails.

Hand WashingHand Washing3. Initial Wash: Wet hands and

forearms under running water and lather them with anti- microbial soap and water for 15-20 seconds, paying particular attention to nails, fingertips, and interdigital spaces.

a. Rinse thoroughly with cool water.

b. Use paper towels to blot and dry hands.

4. Subsequent washes: Wash hands for 15 seconds after removing gloves, between patients, and before leaving the operatory area.

Hand WashingHand Washing When performing oral surgical

procedures perform surgical hand antisepsis by using an antimicrobial product (e.g., antimicrobial soap and water, or soap and water followed by alcohol-based hand

A body area that contacts blood, saliva, or OPIM must be washed immediately after contact.

Any cuts or open wounds need to be covered with a waterproof dressing.

Hand WashingHand Washing Clean sinks fitted with non-touch taps (or carried out

using a non-touch technique). If touch taps are used the taps may be turned on and off with a paper towel.

Alcohol (ethanol or isopropanol) -based hand rubs (ABHR, 70-95%) is the preferred method for hand hygiene in all clinical situations except when hands are visibly soiled (e.g., blood, body fluids).

A compatible moisturiser should be applied up to four times per day or use an emollient-containing ABHR.

ABHR must only be used on dry skin. Position ABHR dispensers close to the clinical

working area (but away from contamination by splash and aerosols)

Personal protection

Personal protective equipment (PPE) includes gloves, eyeglasses, masks, and clinic attire.

Always remove PPE before leaving the clinic area. PPE is not allowed in the hallways.

GlovesGlovesGeneral categories of gloves are:Non-sterile latex: examination and restorative procedures.Sterile latex: surgical proceduresOvergloves: They should be put on when doing tasks that would contaminate items during dental procedures. Examples: answering the phone, writing in a patient’s chart, or leaving the dental chair for any reason.Non-sterile vinylUtility gloves: Made of sterilizable polynitrile and appropriate for cleaning instruments, handling laundry, and other housekeeping tasks. They provide superior protection and can be decontaminated for reuse .

GlovesGloves Wearing gloves does not replace the need

for hand hygiene. Gloves should be put on immediately

before treatment. Gloves must be changed as soon as they

are cut, torn or punctured. Gloves must be removed or overgloves

worn before touching any environmental surface without a barrier or before accessing clean areas.

Gloves must be removed as soon as clinical treatment is complete and hand hygiene undertaken immediately.

The use of powder-free gloves for patient care is recommended strongly

When removing contaminated gloves, grasp them around the wrist and pull them off so that they end up inside out. This will keep the contaminated areas away from your skin. Dispose immediately in a red bag or a biohazard trash

Masks and Protective Eyewear

A disposable mask and eyewear must be worn when spray, spatter, or droplets of blood, saliva, or OPIM will be generated. Goggles or glasses with non-perforated side shields are required. Face shields also provide good protection; they may be used in place of safety glasses.

Masks and Protective Eyewear

Contaminated eyewear should be washed with a disinfectant soap whenever visibly contaminated.

Masks must be changed if they become soaked with moisture or visibly splattered (and always between patients).

Remove mask using ungloved hands. When removing a mask, handle it only by the elastic or cloth tie strings; the mask itself should not be touched.

Treat all masks and glasses as contaminated. Eyewear must be disinfected at the end of

each patient appointment with a surface disinfectant

Clinic AttireLong sleeve- Gowns must be worn

routinely for the following procedures:

[1] Oral or periodontal surgery;[2] Periodontal/hygiene procedures;[3] Restorative procedures where an

aerosol will be generated;[4] Cleaning instruments, biohazard

trash cans, evacuation hoses, and lab equipment;

[5] Loading the clothes washing machine.

If there is no risk of exposure to blood or saliva, short-sleeve attire (scrub top) is acceptable. Such procedures would include patient screening/workup, oral radiology, dispensing sterile instruments or clean dental supplies, and folding clean laundry

Laundry Protocol Contaminated laundry (clinic/lab coats or

gowns, towels, etc.) should be handled as little as possible and placed in appropriately labeled biohazard containers or red laundry bags located in each clinic.

Laundry bags are contaminated and therefore considered biohazardous.

Contaminated laundry will not be sorted or rinsed in the area where it has been used; it will be transported to the laundry room in laundry bags or designated containers.

All sorting and rinsing will be done in the designated laundry area located on the first floor.

Exposure incidentsExposure incidents

Immediate first aid. referral to a qualified health care provider for

exposure follow-up. The source patient must be asked to submit to

testing for hepatitis B, HIV, and hepatitis C.

In spite of the use of protective attire, the risk of accidentalexposure to BBF continues to exist in the dentalsetting. An exposure incident is a specific occupational incident involving the eye, mouth,other mucous membranes, non-intact skin, or parenteral contact with blood, saliva, orOPIM. Minor occupational injuries such as paper cuts or injuries from sterileinstruments are not considered exposure incidents.

Exposure incidentsExposure incidents Post-exposure prophylaxis has been

associated with a decrease of approximately 79% in the risk for HIV seroconversion after percutaneous exposure to HIV-infected blood.

Prophylactic administration is most effective within 1-2 hours following exposure. Early administration affords the most benefit.

Equipment Sterilization

Sterilization of instruments between uses is a fundamental aspect of good infection control practices. Numerous guidelines exist that aid the DHCW in the appropriate method for a given type or classification of instrument.

Instrument ClassificationDental instruments are classified according to their intended use. These classifications assist the practitioner in determining the appropriate method of reprocessing instruments between uses:

Critical instruments: those instruments intended to penetrate soft tissue or bone. These instruments should be sterilized between use or must be disposableSemicritical instruments: not intended to penetrate tissue, but do contact oral tissues. These instruments also require sterilization between uses. If heat sterilization is not feasible, immersion in a high-level sterilant/disinfectant is accepted.Noncritical instruments: contact only intact skin. These items may be processed using an appropriate

intermediate or low-level disinfection .

STERILIZATION/DISINFECTION

Heat-tolerant critical and semicritical items → Sterilization (Steam autoclave, dry heat)

Heat-sensitive critical and semicritical → Sterilization (Glutaraldehyde, glutaraldehydes with phenol, hydrogen peroxide)

Noncritical with visible blood → Intermediate level disinfection → (e.g., chlorine containing products, quaternary ammonium compounds with alcohol, phenolics, iodophors)

Noncritical without visible blood → Low-level disinfection (e.g., quaternary ammonium compounds, some phenolics, some iodophors)

Heat sterilization method:Heat sterilization method: Autoclave: 15-20 min.Autoclave: 15-20 min. Dry heat: 160c 2 hr. Or 170c 1 hr.Dry heat: 160c 2 hr. Or 170c 1 hr. Chemiclave: 131c 20-40 min.Chemiclave: 131c 20-40 min.

Chlorine-based product, a fresh solution of sodium hypochlorite (e.g., household bleach) : ( approximately ¼ cup of 5.25% bleach to 1 gallon of water) Dental practices should follow the product manufacturer’s directions regarding concentrations and exposure time for disinfectant activity relative to the surface to be disinfected.

5 .Work practice control1. Discard or sterilize any instrument or

other item dropped on the floor.2. Do not touch glasses, mask, hair, or

clinic attire during patient treatment.3. Do not keep pens or pencils in the

pockets of clinic gowns during patient treatment if there is the potential for splash or splatter of blood or OPIM

4. If the patient record must be consulted, remove gloves and wash hands before and after handling. If already gloved, you may don overgloves and discard after use.

5. Place all contaminated instruments in appropriate cassettes, metal containers or plastic tubs in which they were initially dispensed.

Environmental Infection Control

1. clinical contact surfaces

2. Housekeeping surfaces

Dental unit disinfectionDental unit disinfection

Dental unit disinfectionDental unit disinfectionFor surface disinfection, use a modified

spray-wipe-spray technique:1. Spray/pour surface disinfectant on

clean gauze or a disposable towel and clean the working surfaces from clean surfaces to most contaminated..

2. With another clean gauze or towel, again spray or saturate with disinfectant and apply to the surfaces.

3. Allow the disinfectant to stay in contact with the surface for the manufacturers recommended time(10 minutes).

Disposal of biomedical waste

Biomedical waste must be: • Stored in colour-coded

containers that are marked with the universal biohazard symbol.

• Released to an approved biomedical waste carrier for disposal.

Dental unit waterlines All waterlines : flushing them

thoroughly with water for at least two to three minutes.

Handpieces: using water coolant should be run for 20 to 30 seconds after patient care

Special Considerations A. Dental Handpieces and Other

Devices Attached to Air and Waterlines

B. Dental Radiology C. Handling of Extracted Teeth D. Dental Laboratory

Asepsis Prior to Treatment

Prior to seating the patient, use the modified spray-wipe-spray technique to disinfect the following:

1. Chair arms, seat, and headrest2. Light handles, evacuation system, and bracket table.

NOTE: The foot control should be left on the floor; it does not require disinfection. Do not spray the back of the light or wipe it with disinfectant since this will damage the reflective paint. Light backs should be considered contaminated and should not be touched during treatment.

3. control levers, seats, and backs;4. Counter tops and amalgamators.

Asepsis Prior to Treatment

Place a sterile tip on the air/water syringe and flush the syringe and hand-piece hoses to dispel stagnant water.

Place disposable plastic tips on high-speed evacuator and saliva ejector.

Place headrest cover over chair back, plastic wrap on air/water syringe handle, patient napkins on operator and assistant carts, and plastic adhesive

cover on light handles and touch pads.

Obtain instruments from dispensary and lay out armamentarium for the procedure.

Place patient chart in chart holder. If there is no specific holder, keep chart away from immediate operating area to avoid contamination.

Asepsis During Treatment

Attention to aseptic technique during patient treatment includes the following:

1. Consider having patient rinse and expectorate with mouthrinse. Rinsing with an approved mouthwash reduces number of microorganisms present on the surface of the oral cavity.

2. Do NOT touch any areas outside immediate operating field during treatment

( hair, face, glasses, mask, patient chart, and/or radiographs).3. Use over gloves to consult chart or radiographs.4. DO NOT ask patient to close lips around the saliva ejector

tip.

Asepsis Following Treatment

After completing the procedure, proper asepsis is accomplished as follows:

1. Remove patient's napkin. Remove gloves, wash hands before completing necessary paperwork and replacing radiographs in chart.

2. Dismiss patient.

3. Put on gloves to place all sharps in sharps container and all instruments in cassettes and/or plastic tub.

4. Flush evacuation system with water for 20 -30 seconds. Flush air/water syringe for 20 - 30 seconds.

5. Place all contaminated items (gauze, cotton rolls, gloves) and all disposableitems (saliva ejectors, evacuation tips) in red plastic biohazard bag attached to operator or assistant cart. Place this bag in the biohazard-labeled trash container in the clinic.

Disinfect/clean chair and all contaminated surfaces using the modified spraywipe- spray technique.

Flush handpiece for 20 -30 seconds. Remove handpiece, clean, disinfect, lubricate then reattach to hose and run handpiece to remove excess lubricant.

Remove handpiece and package it for sterilization. following themanufacturer's directions).

Place contaminated instrument tub on designated transport cart

Remove contaminated gown and place in contaminated laundry bag.

Do not leave clinic area in your gown. Remove overgloves, wash hands, and return unit to

original storage position.

CLASSIFICATION/DECONTAMINATION OF EQUIPMENT, INSTRUMENTS, AND MATERIALS:

SUMMARYAir-water syringes Dispose After each patientAngle attachments Sterilize After each patientDental materials, individual Disinfect containers After each patientFloors, clinic Wash Each morningHandpieces Sterilize After each patientImpression trays Sterilize After each patientInhalation bags (nitrous/oxygen) Dispose After each patientInstruments, dental Sterilize After each patientInstruments, surgical Sterilize After each patientLight-curing units Disinfect After each patientMouth probs Sterilize After each patient

Napkin (alligator) clips Disinfect After each patient

Operatory lights Disinfect/Use barrier After each patient

Operatory chairs Wash/ barrier After each patient Operatory carts Disinfect At end of clinic session Scalers, ultrasonic Disinfect/Sterilize tips After

each patient Suction hoses Disinfect/outer surface After each

patient Suction hoses Flush hose with water After each

patient Telephones, clinic Disinfect Weekly

RESPONSIBILITIES TO PATIENTS WITH

INFECTIOUS DISEASESObligation to Treat: You may not refuse to treat a

patient solely because the patient has an infectious disease. However, departments/clinics may choose to defer non-emergency procedures on patients with airborne infectious diseases until such time as the patient is non-infectious.

Records: All patient dental/medical records must be kept confidential.

Patient Assignment: Patients with active infectious diseases will be assigned to the appropriate clinic or program based on the patient's medical condition, the experience level of the dentist, and the need for or availability of dental allied personnel.

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