INFECTION CONTROL IN DENTISTRY

Dr.Siddharth Dhanaraj.,BDS.,MDS., Lecturer, Dept of Oral & Maxillofacial Surgery Faculty of Dentistry MAHSA University

Hospital Infection & Antibiotic Control Committee ( HIACC )

The Hospital Infection and Antibiotic Control Committee (HIACC) of MOH is responsible for developing policies and procedures related to infection control and antibiotic usage in the hospital and its affiliated health facilities. The HIACC will act as a source of expertise on matters relating to infection and antibiotic usage. The HIACC advises the Hospital Director on the technical matters related to Infection Control in the hospital. The policies and procedures of the HIACC should be in line with the principles and general policies set out by the National Infection and Antibiotic Control

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

CHAIN OF INFECTION
All links must be connected for infection to take place
(sufficient virulence & adequate numbers)

Pathogen

Susceptible Host

(i.e., one that is not immune)

(allows pathogen to survive & multiply)

Source

Entry
(portal that the pathogen can enter the host)

Mode
(of transmission from source to host)

Routine Procedures.
Through medical history

Asymptomatic carriers
Acceptance of patient

It is unethical to refuse dental care to those patient with a potentially infections disease on the grounds that it could expose the dental clinician to personal risk.

Personal Vulnerability
Immunization - Hepatitis B infection Anti HBs levels must be measured 2-4 months after complete immunization course. HBS level > adequate protection. 100 M/U/ml will provided

Single booster dose 5 years after completion of primary course is recommended for all health care workers.

Air borne contamination

High speed hand piece is capable of creating air borne contaminants from bacterial residents from saliva. Aerosols Particle size range from 50 um to approximately 5 um. That can remain suspended in the air and breathed for hrs. Cross infections.

Patients infected usually are not aware of the source of their infection.

Modes of Transmission
Direct contact with blood or body fluids
Indirect contact with a contaminated instrument or surface

Contact of mucosa of the eyes, nose, or mouth with droplets or spatter

Inhalation of airborne microorganisms

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

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

Personnel Health Elements

Personnel Health Elements of an Infection Control Program

Education and training Immunizations Exposure prevention and postexposure management Medical condition management and work-related illnesses and restrictions Health record maintenance

Bloodborne Pathogens

Preventing Transmission of Bloodborne Pathogens

Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV)
Are transmissible in health care settings Can produce chronic infection Are often carried by persons unaware of their infection

Hand Hygiene

http://www.moh.gov.my/images/gallery/Polisi/infection_ control.pdf

Centre for disease control and prevention; Guidelines for Infection Control in Dental Health-Care Settings (www.cdc.gov )
National Institute of Allergy and Infectious Diseases(http://www.niaid.nih.gov/Pages/default.aspx) Occupational Safety and Health Administration(OSHA) https://www.osha.gov/SLTC/etools/hospital/hazards/bb p/bbp.html

National Institute for Health & Care Excellence(NICE) (http://www.nice.org.uk/CG139 )

Why Is Hand Hygiene Important?

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

Prevent health care-associated

infections

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)

Hand Hygiene Definitions

Handwashing
Washing hands with plain soap and water

Antiseptic handwash
Washing hands with water and soap or other detergents containing an antiseptic agent

Alcohol-based handrub
Rubbing hands with an alcohol-containing preparation

Surgical antisepsis
Handwashing with an antiseptic soap or an alcoholbased handrub before operations by surgical personnel

Efficacy of Hand Hygiene Preparations in Reduction of Bacteria

Good
Better Best

Plain Soap

Antimicrobial soap

Alcohol-based handrub

Source: http://www.cdc.gov/handhygiene/materials.htm

Alcohol-based Preparations
Benefits
Rapid and effective antimicrobial action Improved skin condition

Limitations
Cannot be used if hands are visibly soiled Store away from high temperatures or flames Hand softeners and glove powders may build-up

More accessible than sinks

Special Hand Hygiene Considerations

Use hand lotions to prevent skin dryness Consider compatibility of hand care products with gloves (e.g., mineral oils and petroleum bases may cause early glove failure) Keep fingernails short Avoid artificial nails Avoid hand jewelry that may tear gloves

Personal Protective Equipment

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 treatment areas

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

Sterilization and Disinfection of Patient Care Items

Critical Instruments
Penetrate mucous membranes or contact bone, the bloodstream, or other normally sterile tissues (of the mouth) Heat sterilize between uses or use sterile singleuse, disposable devices Examples include surgical instruments, scalpel blades, periodontal scalers, and surgical dental burs

Semi-critical Instruments
Contact mucous membranes but do not penetrate soft tissue

Heat sterilize or high-level disinfect

Examples: Dental mouth mirrors, amalgam condensers, and dental handpieces

Noncritical Instruments and Devices

Contact intact skin

Clean and disinfect using a low to intermediate level disinfectant Examples: X-ray heads, facebows, pulse oximeter, blood pressure cuff

Methods of Infection control

Sterilization Sterilization is the destruction or complete removal of all forms of micro organisms. Disinfection Disinfection is the destruction of many microorganisms but not usually the bacterial spores.

Steam Pressure (Autoclaving)

Sterilization

Long cycle of 15 min 121 degree Celsius and 15 lbs pressure. Short cycle of 7 min 134 degree Celsius and 30 lbs pressure. Advantage of autoclaves - Most rapid and effective methods for sterilization of commonly used dental equipments. Disadvantages of Autoclaves Can cause rusting of carbon steel instruments. Dental burs can be autoclaved after dipping it into 2

Dry Heat Sterilization Hot air oven

Dry heat at 160 degree Celsius for commonly used for this purpose. Microbial inactivation by dry heat is primarily an oxidation process. Employed for sterilization of glassware, glass syringes, oils and oily injection as well as metal instruments. Chemiclaving Using ethylene oxide gas 131 degree celcius 20 pounds pressure is use for this purpose. Heat sensitive plastic instrument are sterilized by this method.

New methods of sterilization

Using - ultra violet light and gamma rays Not effective against RNA viruses like HIV and bacterial spores. Ultrasonic sterilization.

Not commonly employed in dental practice.

Glass bead sterilizer used for sterilization of endodontic files.

Types of instruments sterilization methods.

and

Hand piece Should be well disinfected before sterilization Hot oil sterilization can be used for this. Autoclaving is commonly carried out. Sterilization of impression (Vinyl Polysiloxane) or Rubber Based Impression. These are sterilized by dipping them in 2 % gluteraldehyde solution for minimum of 2 hours. These should be wrapped in sterile bag.

NEEDLE STICK INJURY

Needle stick injury one of the most common hazard which dental professional and other medical professional usually come across.
The risk of transmission of HIV and Hepatitis B is most dangerous. For Hepatitis B It is always better for any health care worker to be well vaccinated with HBs vaccine.

For HIV as soon as one comes across needle stick injury

1. Hands should be washed thoroughly with the available disinfectant. 2. The area of the injury should be squeezed of for allowing blood to flow out of it. 3. The patient can be ask for his HIV or Hepatitis B status. 4. The senior medical incharge informed about the accident. should be

5. HIV postexposure chemoprophylaxis for health workers.

Basic (28 days) Zidovudine + Lamivudine

Expanded (28 days) As above + Indinavir or nelfinavir or neviriapine

6. PCR (polymerized chain reaction) can detect the presence of HIV p24 antigen within 24 hrs of initial infection. 7. Check up with ELISA in every six months. 8. The risk of HIV transmission by needle stick injury is only 0.03 %

What is the role of OSAP?

The Organization for Safety and Asepsis Procedures (OSAP) is a group of dental workers, scientists, teachers, and product manufacturers and distributors. They work together to provide infection control and safety information to dental personnel around the world.

OSAP is considered the leading resource for infection control and safety information in dentistry.

2004, p. i.

From Policy to Practice: OSAPs Guide to the Guidelines,

Scrubs
If a pullover style is worn if large amount of contamination, the employee is to be trained how to remove without contact to the face

Segregation & Disposal of hospital waste (1)

Waste should be segregated & suitably disinfected before disposal Classification of Hospital waste:
Infectious/Hazardous :
Human Anatomical waste: Human tissues, organs, parts, Blood, Blood bags Sharps Needles, syringes, scalpels, blades, glass etc Soiled Wound dressings, swabs, mops , bandages Laboratory - Pathology ,Microbiology

Non Infectious:
General waste - paper, plastic bags , bouquets Kitchen waste

Segregation must be done in colour coded containers

Segregation & Disposal of hospital waste (2)

Red: All plastics-Disposable syringes,Blood bags,IV

tubings,Urine bags etc

Yellow: Body parts, Histopathology specimens, human

tissue, organs, microbiology waste. soiled waste, swabs, dressings , mops ,bandages etc

Green :General waste, Kitchen waste

White Puncture proof Containers :Needles,glass
ampoules, nails, blades, lancets etc Disinfection methods :1%Sodium hypochlorite, Autoclaving.

ORGANISATIONS

Centre for Disease Control http://www.cdc.gov/oralhealth/infectioncontrol/guidelin es/infection_control_guidelines.ppt ) Policies and Procedures on Infection Control , MOH malaysia http://www.moh.gov.my/images/gallery/Polisi/infection _control.pdf National Institute for Health & Care excellence(NICE) http://www.nice.org.uk/CG139 WHO http://www.who.int/topics/infection_control/en/