INFECTION CONTROL IN DENTAL PRACTICE Dr Arun George MDS Maxillofacial Surgeon, India Mar Baselios Dental College http://www.wakingtimes.com/2013/05/16/the-spiritual-eye-how-to-decalcify-awaken-your-pineal-gland/

STERILIZATION INSTRUMENT MANAGEMENT

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 During the provision of dental treatment, both patients and dental health care personnel (DHCP) can be exposed to pathogens through contact with blood, oral and respiratory secretions, and contaminated equipment. Following recommended infection control procedures can prevent transmission of infectious organisms among patients and dental health care personnel.

Dental patients and dental health care workers may be exposed to a variety of microorganisms such as bacteria, viruses, and fungi during dental treatment Among these, the diseases of foremost concern are infections caused by Human immunodeficiency virus (HIV) Hepatitis viruses B, C, and D Mycobacterium tuberculosis

Infections may be transmitted in the dental operatory through the following routes Direct contact with blood, oral fluids, or other secretions Indirect contact with contaminated instruments, operatory equipment, or environmental surfaces Contact with airborne contaminants present in either droplet spatter or aerosols of oral and respiratory fluids

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 Dental patients and DHCP may be exposed to a variety of disease-causing microorganisms that are present in the mouth and respiratory tract. These organisms may be transmitted in dental settings through several routes, including: Intact or non-intact skin in direct contact with blood, oral fluids, or other potentially infectious patient materials. Indirect contact with a contaminated object (e.g., instruments, operatory equipment, or environmental surfaces). Contact of mucous membranes of the eyes, nose, or mouth with droplets (e.g., spatter) containing microorganisms generated (e.g., coughing, sneezing, talking) from an infected person and propelled a short distance. Inhalation of airborne microorganisms that can remain suspended in the air for long periods of time.

Route of transmission Inoculation: Direct contact of previously damaged skin or mucous membrane with a lesion, organism, or debris while performing intra-oral procedures. Accidental self injury with a contaminated needle, or sharp instruments

Inhalation Inhalation of microorganisms aerosolized from a patient’s blood or saliva occurs when using high speed or ultrasonic instruments

Universal precautions Universal precautions are a set of precautions designed to prevent transmission of HIV, HBV, and other blood borne pathogens when providing first aid or health care Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV, and other blood borne pathogens

Needles, scalpels, and other sharp instruments or devices Universal precautions - involve the use of protective barriers such as gloves, gowns, aprons, masks, or protective eye wear Needles, scalpels, and other sharp instruments or devices which can reduce the exposure of skin and mucous membrane to potentially infective materialsIn addition, it is recommended that all health care workers take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices

Hand Hygiene & Personal Hygiene Hands are the most common mode of pathogen transmission Reduce spread of antimicrobial resistance Prevent health care-associated infections Next we turn to the subject of Hand Hygiene. So, is hand hygiene the single most important factor in preventing the spread of pathogens in health care settings? First, hands are the most common mode of pathogen transmission. Hand washing can reduce the spread of antibiotic resistance in health care settings and the likelihood of health care-associated infections. [Additional comments: CDC estimates that each year nearly 2 million patients in the United States acquire infections in hospitals, and about 90,000 of these patients die as a result.]

Personal Hygiene Visibly dirty After touching contaminated objects with bare hands Before and after patient treatment (before glove placement and after glove removal) CDC recommends that hands be cleaned: When they are visibly dirty. After touching contaminated objects with bare hands. Before and after patient treatment, that is, before glove placement and immediately after glove removal. Photo credit: Centers for Disease Control and Prevention, Atlanta, GA.

Personal Hygiene No finger nails and rings No watch Put up u r hair

Personal hygiene All dental staff who come into direct contact with patients should practice meticulous personal hygiene Fingernails must be kept short and jewellery on the hands and watches should be removed since they tend to trap organisms and may tear the gloves Hair should be put up tightly It is a good practice to wash the hands before and after treatment with a non-irritant antimicrobial hand wash solution Do not touch one’s own eyes, nose, mouth, hair or other items like patient records, computer key boards, telephone receiver, drawer handles, pen etc with contaminated hands Never leave the clinic wearing aprons or overcoats

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 alcohol-based handrub before operations by surgical personnel Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis. Handwashing refers to washing hands with plain soap and water. Antiseptic handwash refers to washing hands with water and soap or other detergents containing an antiseptic agent, such as triclosan or chlorhexidine. Using a waterless agent containing 60%–95% ethanol or isopropanol alcohol-containing preparation is referred to as an alcohol handrub. These agents are a new addition to the dental guidelines and have become more frequently used in the United States to improve compliance with handwashing in hospitals. In dental practices, however, sinks are readily available and the need for alcohol preparations is not as great. Surgical antisepsis refers to an antiseptic handwash or alcohol-based handrub* performed preoperatively by surgical personnel to eliminate microorganisms on hands. Antiseptic preparations for surgical hand hygiene should have persistent (long-lasting) antimicrobial activity. * If using an alcohol-based handrub the hands should first be washed with soap and water.

Barrier techniques The proper use of barrier techniques as part of universal precautions is extremely important The wearing of gloves, masks, protective eyewear, and clinic attire by all personnel who have direct contact with the patient is required for all treatment, regardless of their nature

Gloves Surgical gloves Examination gloves Utility gloves: heavy rubber gloves used for cleaning instruments and environmental surfaces Gloves can be autoclaved and reused; but they must be discarded if they are cracked, discolored or have punctures, tears or other evidences of deterioration

Aerosols Aerosol is defined as small droplets, usually 50 μm or less in diameter, which can remain suspended in air for some time. The smaller particles of an aerosol have the potential to penetrate and lodge in the smaller passages of the lungs and are thought to carry the greatest potential for transmitting infections Diseases such as tuberculosis, influenza, and SARS (Severe Acute Respiratory Syndrome) are known to be spread by droplets or aerosols

Dental handpieces, airotors, air/water syringes, and ultrasonic scalers produce large amounts of aerosols. The risk of infection from aerosols can be minimized by Use of protective barriers Pre-procedural rinsing with 0.2% chlorhexidine; reduces the bacterial count in the aerosols Proper patient positioning Use of saliva ejectors and high volume suctions

Saliva Ejectors Previously suctioned fluids might be retracted into the patient’s mouth when a seal is created Do not advise patients to close their lips tightly around the tip of the saliva ejector Backflow, meaning reverse flow, can occur when there is more negative pressure in the patient’s mouth than in the evacuator tubing, for example, when the patient uses the saliva ejector as a straw. When this happens, material from the mouth of a previous patient might remain in the vacuum line of the saliva ejector and be aspirated into the mouth of the next patient being treated. Although there have been no reports of any adverse health issues, patients should not be instructed to close their lips tightly around the saliva ejector tip during use. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

HIGH VOLUME EVACUATION (SUCTION) SALIVA EJECTOR

Biofilms Adhesion of bacteria and other microorganisms to solid surfaces in aqueous environments can result in the formation of a slime-like material called biofilm Biofilm protects the bacteria from disinfectants and can trap other potentially infective microorganisms

Biofilms can form within dental water lines by two ways Bacteria may be pulled into the water lines during treatment from the patient’s mouth which may later transmit to other patients Bacteria present in the main water supply can concentrate in the dental unit water line especially in warm and stagnant conditions

Biofilm formation can be minimized by Independent water reservoirs for the dental unit Using sterile water Drain and flush water lines for several minutes before beginning clinic each day After each patient, run high-speed handpieces and scalers for a minimum of 20-30 seconds to discharge contaminated water and air that may have entered the water line

Dental Unit Waterlines and Biofilm Microbial biofilms form in small bore tubing of dental units Biofilms serve as a microbial reservoir Primary source of microorganisms is municipal water supply Studies have shown that colonies of microorganisms, or biofilms, can form on the inside of the small-bore plastic tubing that transports water within the dental unit to handpieces and air-water syringes. Once formed, a biofilm serves as a reservoir that may dramatically increase the number of free-floating microorganisms in water used for dental treatment. Most organisms isolated from dental water systems originate from the public water supply and do not pose a high risk of disease for healthy persons. Although a few pathogenic organisms, such as Legionella spp. and Pseudomonas sp., have been found, adverse public health threats have not been documented. Photo credit, top: CDC Image library. This Scanning Electron Micrograph depicts an E. coli (ATCC 11775) biofilm grown on PC (polycarbonate) coupons using a CDC biofilm reactor. Photo credit, bottom: Illustration from the Center for Biofilm Engineering, Bozeman MT.

Flushing the scalers and handpieces (bleeding) for 30 seconds between each patient can discharge the contaminated water that have entered the water line

Handling of sharp instruments Care must be taken while handling needles and other sharp instruments during and after procedures, while cleaning used instruments, and during disposal of used needles. Forceps must be used to handle sharp instruments Disposable needles, scalpel blades and other sharp items should be discarded into puncture-resistant containers that are easily accessible for disposal

When recapping needles, both hands should never be used; instead, a one-handed “scoop technique” or another instrument should be used “scoop technique” Wrong method

Handling sterile instruments Never touch sterile instruments or other materials like cotton with contaminated gloved hand or used instruments Sterilized materials and instruments should be handled with a sterilized cheatel forceps, which should be stored with the tip immersed in a disinfectant solution

Chittle Forceps

Anaesthetic Solution

Local Anaesthetic If repeated injections are required, the used syringe should be discarded and a new one taken

Special Considerations Dental handpieces and other devices attached to air and waterlines Dental radiology Single-use (disposable) Devices Preprocedural mouth rinses Oral surgical procedures Handling biopsy specimens Handling extracted teeth Laser/electrosurgery plumes or surgical smoke Dental laboratory Mycobacterium tuberculosis Creutzfeldt-Jacob Disease (CJD) and other prion-related diseases

Sterilization Process by which all forms of microorganisms including viruses, bacteria, fungi, and spores over articles or surfaces are destroyed Articles or objects free of living organisms are termed sterile

Methods of sterilization Moist heat (autoclaving) Dry heat (hot-air oven) Chemicals (chemiclaving)

Most preferred method of sterilization Steam Under pressure

Recommended sterilization cycles for autoclaving Temperature Time Pressure Unwrapped instruments 1340C 3 min 30 psi Wrapped 1210C 15-20 min 15 psi

Packaging and sealing of instruments Instruments should be carefully packaged in functional sets before sterilization. This packaging protects the instruments after sterilization and before use at chair side A variety of packaging materials are available Self-sealing, paper-plastic, peel pouches are the most convenient

Some packaging materials have indicators which change color when sterilization is completed

Boiling Immersion of instruments in boiling water does not achieve sterilization as many of the bacterial spores can withstand boiling Cross infection from contaminated water containing bacterial spores not killed by boiling is also a possibility

Classification of Instruments to be Sterilized Dental instruments are classified into three categories depending on their risk of transmitting infection and the need to sterilize them between use critical Semi-critical Non-critical

Critical Surgical and other instruments used to penetrate soft tissue or bone Should be sterilized after each use Examples are Forceps, periosteal elevators, cross bars Scalpels, scissors, suture needles Bone chisels Surgical burs Scaling instruments Endodontic instruments

Semi-critical Instruments that do not penetrate soft tissue or bone but contact oral tissues These instruments should also be sterilized after each use Examples are Mouth mirrors Burs Handpieces Tweezers Restorative instruments Impression trays

Non-critical Those items, which do not come into contact with body fluids Have a relatively low risk of transmitting infection Examples are Medication bottles Light cure tips Glass slab and cement spatula Instrument trays Orthodontic pliers Dapen dish

Surface asepsis Use surface barriers to protect clinical contact surfaces, particularly those that are difficult to clean (e.g., switches on dental chairs) Change surface barriers between patients

Disinfection of Dental Equipments Clinical contact surfaces and dental equipments that are not covered should be cleaned and disinfected with a hospital level disinfectant (activity against HIV, HBV, and Mycobacterium tuberculosis) after each patient. Sodium hypochlorite (household bleach) is an effective and economical surface disinfectant

DISINFECTANTS

Antiseptics Biguanides: Chlorhexidine Low toxicity Used on skin and mucous membranes

Clinical Contact Surfaces This slide shows some examples of clinical contact surfaces, including a light handle, countertop, bracket tray, dental chair, and door handle (shown by arrows). Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Housekeeping Surfaces Examples of housekeeping surfaces are walls, sinks, and floors (shown by arrows). Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Spray-wipe-spray technique Spray the disinfectant solution on the surface Using a gauze piece, wipe the surfaces in overlapping strokes Spray again Allow the disinfectant to dry on the surface for about 10 minutes

Autoclaving

U V Chamber Ultraviolet germicidal irradiation (UVGI) is a disinfection method that uses short-wavelength ultraviolet (UV-C) light to kill or inactivate microorganisms by destroying nucleic acids and disrupting their DNA, leaving them unable to perform vital cellularfunctions.[1] UVGI is used in a variety of applications, such as food, air, and water purification. UV-C light is weak at the Earth's surface as the ozone layer of the atmosphere blocks it.[2] UVGI devices can produce strong enough UV-C light in circulating air or water systems to make them inhospitable environments to microorganisms such as bacteria, viruses,molds and other pathogens. UVGI can be coupled with a filtration system to sanitize air and water. The application of UVGI to disinfection has been an accepted practice since the mid-20th century. It has been used primarily inmedical sanitation and sterile work facilities. Increasingly it has been employed to sterilize drinking and wastewater, as the holding facilities are enclosed and can be circulated to ensure a higher exposure to the UV. In recent years UVGI has found renewed application in air purifiers.

Instrument Storage

Autoclaved Towel

Gloves

Hand Disinfectants

Alcohol Alcoho

Dental Handpieces and Other Devices Attached to Air and Waterlines Clean and heat sterilize intraoral devices that can be removed from air and waterlines Follow manufacturer’s instructions for cleaning, lubrication, and sterilization Do not use liquid germicides or ethylene oxide Any removable device that is attached to the air or waterlines should be heat sterilized to ensure that internal components have been sterilized. It is very important to follow the manufacturer’s instructions for cleaning and lubrication. These protocols can ensure the effectiveness of the process and contribute to the life of the device. Surface disinfection or liquid chemical germicide immersion are not acceptable. In addition, the use of ethylene oxide is not recommended because it cannot reliably penetrate the internal components.

Handpiece Disinfection & Oiling Handpiece piece cleaning mechanism……

Hand pieces should be dried and kept upsaid down after proper oiling and disinfecting and can be taken up for autoclaving for any surgical uses.

Air Compressor Air filters to be attachd to all aircompressors…… if needed periodically remove and clean the filters…….

Waste Management Dental clinic waste should be handled properly and should be transported for proper waste disposal……most of the clinics in kerala will have image will have image waste disposal system……

Sharp Instruments

Dental Chair Care Chair needs to be raised for proper drainage and biofilim formation, Disinfectant solution can be used to inside the suction and drainage channels periodically.

Apron

Infection Control Program Goals Provide a safe working environment Reduce health care-associated infections Reduce occupational exposures The goal of an infection control program is to provide a safe working environment for DHCP and their patients. We can accomplish this by adopting measures that will reduce health care-associated infections among patients and occupational exposures among DHCP.