Infection Prevention & Control in Dentistry PDF

Infection Prevention & Control in Dentistry Kelvin Kamupira Aims & Objectives The purpose of this session is to provide relevant information relating to principles of infection prevention & control in dentistry 2 Learning O...

Infection Prevention & Control in Dentistry Kelvin Kamupira Aims & Objectives The purpose of this session is to provide relevant information relating to principles of infection prevention & control in dentistry 2 Learning Outcomes and Objectives By the end of the session you should be able to: Explain the importance of infection prevention & control to the patient, dental team & wider public Identify dangers in the dental surgery Differentiate between decontamination, disinfection and sterilisation techniques Have knowledge of PPE & its correct usage Describe clinician responsibilities in preventing cross infection, the need for up-to-date immunisation & why proper cleaning is essential Understand the zoning technique to ensure environmental infection control Explain inoculation injuries and their avoidance in the dental workplace Recognise the need for proper waste disposal 3 GDC Learning Outcomes (2013) 1.1.7 Explain the potential routes of transmission of infectious agents in dental practice, mechanisms for the prevention of infection, the scientific principles of decontamination and disinfection and their relevance to health and safety 1.8.2 Implement and perform effective decontamination and infection control procedures according to current guidelines What do you understand by Infection Control? Quiz Time Infection control It is the methods & measures employed in a workplace (in this case, dental workplace) To prevent everyone from getting contaminated by or acquire an infection from a patient or another member of staff, or from a dirty instrument. Statistics 7 in 100 patients, in developed countries and 10 in 100 patients in developing countries will acquire at least one health- care related infection. It is estimated that sharps injuries cause about 66,000 HBV, 16,000 HCV and 200- 500 HIV infections among health-care workers each year. For health-care workers worldwide this equates to 37%, 39% and 4.4%, respectively (WHO 2003) There were an estimated 834 000 HCAIs in 2016/2017 costing the NHS £2.7 billion, and accounting for 28,500 patient deaths.(BMJ 2019) Who is at Risk? Dentist Hygienist/ Therapist Dental Nurse Families/ commuting Technician Patient Why Infection Control is Important in Dentistry All members of the dental team have a duty of care to protect their patients, colleagues & themselves coming to harm while in a dental workplace (DH 2013) Importantly prevent getting contaminated or acquiring an infection from a patient or a member of staff, or a dirty instrument. Bigger picture Ecological changes Unexplained Changes in human emergence behaviour & demographics Breakdown in International public health travel and measures commerce Microbial changes Background 13 Background 14 Anyone want to share personal experiences? Regulation Registration for healthcare providers in England is overseen by CQC Compliance with essential quality requirements of HTM 01-05 (2013) ensure each workplace meets registration requirements of the CQC Compliance with the GDC Standards Health Technical Memorandum (HTM 01-05) gov.uk Need for Infection Control in Dentistry Mouth is full of micro- organisms Instruments used in dentistry become contaminated whenever used If no action was taken to clean items after use – micro- organism contamination would pass on via cross-infection. 19 Cycle of Infection (Aim is to break the cycle) Source: BDJ Dangers in the Surgery Pathogenic micro-organisms of concern to the dental team Herpes Simplex type I Hepatitis B Hepatitis C New-variant Creutzfeldt-Jakob Please refer to separate lectures disease (vCJD) Human immunodeficiency virus (HIV) COVID-19 & any AGPs How do we ensure we are protected before we start delivering clinical care? All dental staff should receive the following immunisations before working at the chair side Poliomyelitis Tuberculosis Tetanus MMR (measles, mumps & rubella) Diphtheria Pertussis (whooping cough) Hepatitis B 23 Personal Protective Equipment Worn to protect staff from coming into contact with blood and other bodily fluids Legal requirement for dental employers to provide PPE for their staff Should be worn correctly as stipulated in Infection Control policy Refer to Infection Control​ Policy Use of Personal protective Equipment (PPE) Uniform UCLH Dress code & Uniform policy requires all patient facing staff (including dental) to It is for infection control wear a uniform and health & safety purposes Footwear Why? Footwear must be safe, sensible with a flat/low heel and in good order Covering all toes with good soles & heels which do not make unnecessary noise in a clinical area Nursingtoes.co.uk  Nails, Hair, Jewellery, Piercings etc Nail varnish, nail extensions and false One small earring only per ear nails must not be worn – nails should be short. No necklaces Long hair must be tied both back & up so Body piercings must be covered that it does not fall below the shoulders with a plaster during work Long fringes must be clipped back or held For cultural reasons only, small in place with a band to avoid `hand-hair` discreet nose stud is allowed contact Dental nurse loses discrimination case after refusing to cut nails – Dentistry Plastic Apron (Single use) To be worn over the uniform during procedures when soiling may occur or while cleaning the clinical area.  Wearing gloves Come in varying quality Can be latex or non-latex Should be changed in between patients unless torn or heavily soiled Hands frequently become contaminated during removal NB. Wearing gloves is no substitute for hand washing. Facemasks Medicalexpress.com Facemasks For AGP procedures you must don the mask you have been fit-tested on, when treating a patient known or suspected to be suffering from an infectious agent transmitted partly or wholly via airborne or droplet route. Protective Eye Wear A visor or face shield should be worn NB Clean eye protection with disinfectant wipes in between patients Loupes Will need to substitute for protective eye wear, but must be worn with a facemask Hand Hygiene Hand Hygiene Covers not only hand washing but additional measures such as hand disinfection using anti-bacterial based hand rubs/gels Important in preventing the spread of infection & the recontamination of sterile instruments and devices Clean hands are an essential counterpart to the use of gloves Neither measure is a substitute for the other When is Hand hygiene important? 1. Before & after each treatment session 2. Before & after removal of PPE 3. After the washing of dental instruments 4. Before contact with instruments that have been steam-sterilised 5. After the completion of decontamination work 6. After cleaning or maintaining decontamination devices used on dental instruments 47 Hand Washing Dedicated hand-washing sinks must be available in the dental workplace Taps should be operated by either elbow or by foot to avoid recontamination Nails should be kept short & jewellery removed Mild liquid soap should be used According to WHO, Hand washing should take 40-60 seconds Handwashing Steps using the WHO technique video https://youtu.be/aGJNspLRdrc?feature=shared Improper handwashing technique Alcohol based Hand Rub (not a replacement for handwashing) Alcohol Based Hand Rub BENEFITS LIMITATIONS Cannot be used if hands are Rapid & effective visibly soiled antimicrobial action Follow instructions on amount Reduced time for hand to `gel` disinfection Highly flammable – implement More accessible than safety precautions sinks Cannot be used repeatedly Skin Care Use approved hand creams or lotions Check compatibility with the manufacturer Some lotions may make medicated soap less effective Some cause breakdown of latex gloves e.g., petroleum based Lotions can become contaminated with bacteria if dispensers are refilled Cleaning and getting rid of micro-organisms Social cleaning -clean to a socially acceptable standard but not disinfected nor sterilised Disinfection – the killing/destruction of bacteria & fungi, but not spores nor some viruses (technique usually involves use of chemicals) Sterilisation – the process of killing all micro-organisms to produce asepsis. Involves use of autoclaves Asepsis – the absence of all living pathogenic micro-organisms Cleaning the clinical area The whole of the dental area should be cleaned to a socially acceptable standard (usually carried out by a domestic cleaner) Standard of cleaning to be achieved in a clinical area is disinfection Clinical area should be designated as `clean` and `dirty` so that dirty instruments are not placed where clean items should be placed This is called ZONING Preparing the Dental chair Clinical contact surfaces: Surfaces contaminated from patient materials either by direct spray or spatter generated during dental procedures or by contact with the dental care professional`s gloved hands What needs to be cleaned between patients? Protective Barriers  Clearing and cleaning after each patient The biggest risk to injury or infection occurs during the clean-up & disposal stage  You must wear gloves to reduce cross- infection 1 Remove sharps first & dispose of appropriately 2 Ensure all instrument trays are securely closed before placing in the `dirty` zone 3 Disinfect the chair, bracket table, including body of 3 in 1 syringe, slow speed motor and holder, operating light and spittoon 4 Wipe all surfaces with disinfection wipes 5 Preventing needlestick injuries An Educational Video - Needle Stick In juries – YouTube https://www.youtube.com/watch? v=PEI9QmGErWs Needlestick injuries Injuries from needles used in medical procedures are sometimes called needle- stick or sharps injuries Sharps can include other medical supplies, such as syringes, scalpels and lancets, and glass from broken equipment Once someone has used a needle, viruses in their blood, such as hepatitis B, hepatitis C or HIV, may contaminate it. This includes needles used to inject illegal drugs. Blood can also contaminate sharps https://my.uclh.nhs.uk/Interact/Pages/Content/Document.aspx?id=19933  Dental Unit Water Line (DUWL) & Biofilm What is Biofilm? A layer of micro-organisms contained in a matrix (slime layer), which forms on substances in contact with water. British Society of Immunology 63 Risk to Staff and Patients According to the World Health Organisation water should be free from any organism that might pose a health risk to the human population (WHO 2015) Most contaminants are non-pathogenic This is however considered in immuno-suppressed individuals Concern is over opportunistic respiratory pathogens such as Legionella and non - TB Mycobacterium Type of Bacteria in the DUWL Bacteria is coming from the mains water Less likely oral bacteria DUWL bacteria form very quickly More resistant to treatment with antimicrobials, UV & disinfectants Reducing Biofilm TARGET OPTIONS Water lines should be flushed at the Management systems to try beginning of the day and in between and keep acceptable level patients to reduce risk of suck-back Dental units and water lines should be flushed out at the end of each day (flushing reduces bacterial count by 97%) Water lines should be disinfected weekly NB. DUWL are classed as according to instructions medical devices For extended periods of unuse (e.g., bank holidays, Christmas), use Bilpron. It can prevent biofilm formation for up to 3 months Flushing of Dental Units Part of setting up the dental bay activity Reducing Biofilm Sterile bottled water is Also follow recommended instead of water from surgery tap Practice protocol CQC guidelines Prevent contamination of the mains water supply using a physical air gap and of the waterline using point of use filters Decontamination Decontamination – also referred to as `reprocessing`, is the process used to remove contamination from reusable items, so that they are safe for further use on patients & staff to handle. Involves the following four stages. 1. Cleaning 2. Disinfection 3. Inspection 4. Sterilisation Cleaning of reusable instruments before sterilisation Should meet Essential quality requirements according to HTM 01- 05. Cleaned instruments should be free of visible contaminants prior to sterilisation regardless of method used (Ultrasonic, Washer-disinfector) Cleaning of equipment, instruments and handpieces Three main techniques currently used for cleaning reusable dental equipment. Manual cleaning Decontamination & cleaning with Manual cleaning with ultrasonic washer- decontamination disinfector Autoclaving (moist heat) sterilisation Boiling water alone is INSUFFICIENT to kill spores & viruses Effective autoclaving 1. Temperature =134ºC 2. Pressure = 32lb/sq (Psi) 3. Cycle time = 3.5min Dry heat sterilisation A`Hot Air oven` is used Suitable for instruments with sharp cutting edge Please refer to HTM 01-05 Doc 75 Chemical Disinfection Suitable for instruments & working surfaces Limitations Efficient at certain concentration & temperature Object must be thoroughly cleaned Each agent needs a certain minimum exposure time Shelf life Certain chemicals may damage some surfaces NB. Alcohol has been shown to bind blood and protein to stainless steel and the use of alcohol with dental instruments should therefore be avoided Sterile Single Use Instruments  Waste Disposal Mandatory Training Clinical waste, is waste that is contaminated with blood, saliva or other body fluids & may prove hazardous to any person coming in to contact with it. It is disposed of in the appropriately labelled bins on clinic (tiger striped) There are other bins on clinic for non–clinical waste such as recycled waste. NEVER touch clinical waste with ungloved hands  Sharps Boxes All used needles, used burs, matrices etc. must be placed in the sharps box ( please do NOT dispose of reusable burs/mandrels etc.) LA cartridges whether partially or fully discharged must always be disposed of via sharps container Sharps container should be disposed of when no more than 2/3 full Further Reading  UCLH Staff Intranet  Infection control policy  Hand hygiene policy  Uniform policy GDC Standards Document  World Health Organisation website  www.who.int  SDCEP Infection Control in Dental Practice  Infection control in dental practice | Practice Support Manu  Health Technical Memorandum 01-05 (HTM 01-05)  Health Technical Memorandum 05-01: Decontamination in primary care dental prac tices  CQC Guidelines and Quality Compliance  Guidance and regulation - Care Quality Commission