Infection Control In Dentistry PDF

INFECTION CONTROL IN DENTISTRY BY DR V. VASUNDHARA DEPT OF CONSERVATIVE & ENDODONTICS KVGDC, SULLIA • Introduction and history •Personal protection •Sterilization disinfection and asepsis •Universal precautions •Osha guidelines for dentistry •Categories of clinical environmental surfaces •Waterl...

INFECTION CONTROL IN DENTISTRY BY DR V. VASUNDHARA DEPT OF CONSERVATIVE & ENDODONTICS KVGDC, SULLIA • Introduction and history •Personal protection •Sterilization disinfection and asepsis •Universal precautions •Osha guidelines for dentistry •Categories of clinical environmental surfaces •Waterline bio-films management •Sterilisation in operating room •Exposure prevention strategies •Post-exposure management •Pre-exposure management •Diseases we must be aware of…. •Infection control in dental radiology •Dental laboratories •Considerations for biopsy specimens •Waste disposal •Reference s 2 SCIENTISTS:  Louis Pasteur (France) 18221895 - microbiology emerged as a scientific discipline during his course. - developed steam sterilizer, autoclave and hot air oven. leewenhoek 3  Policies and procedure used to prevent or reduce the potential for disease transmission Cottone’s practical infection control in dentistry Infectious agent Susceptible host Reservoir Port of Entry Port of Exit Transmission PATHWAYS OF INFECTION TRANSMISSION IN A DENTAL OFFICE •PATIENT TO DENTAL TEAM •DENTAL TEAM TO PATIENT •PATIENT TO PATIENT •DENTAL OFFICE TO COMMUNITY, INCLUDING THE DENTAL TEAMS FAMILIES • FROM COMMUNITY TO PATIENT 7 PATIENT TO DENTAL TEAM SOURCE OF MICROORGANISM MOUTH MODE OF DISEASE SPREAD DIRECT CONTACT DROPLET INFECTION INDIRECT CONTACT PATIENTS SKIN LESIONS MECHANISM OR SITE OF ENTRY INTO BODY THROUGH BREAKS IN SKIN INHALATION THROUGH MUCOSAL SURFACES THROUGH CUTS AND PRICKS 8 DENTAL TEAM TO PATIENT SOURCE OF MICRO ORGANISM DENTAL TEAM HANDS, SKIN LESIONS DENTAL TEAM MOUTH MODE OF DISEASE SPREAD DIRECT CONTACT INDIRECT CONTACT DROPLET INFECTION MECHANISM OR SITE OF ENTRY INTO BODY THROUGH MUCOSAL SURFACES OF PATIENTS BLOOD CONTAMINATION OF INSTRUMENTS INHALATION BY PATIENT 9 PATIENT TO PATIENT SOURCE OF MICROORGANISMS PATIENTS MOUTH MODE OF DISEASE SPREAD INDIRECT CONTACT THROUGH INSTRUMENTS SURFACES, HANDS MECHANISM OR SITE OF ENTRY INTO BODY HROUGH ORAL MUCOSAL SURFACES OF PATIENT 10 DENTAL OFFICE TO COMMUNITY SOURCE OF MICROORGANISMS PATIENTS MOUTH MODE OF DISEASE SPREAD INDIRECT CONTACT MECHANISM OR SITE OF ENTRY INTO BODY CUTS, PUNCTURES, BREAKS IN SKIN, WASTES, LAB PROCEDURES 11 Screening of all patients is the first step in PATIENT SCREENING minimizing and reducing the risk of infectious disease transmission From patients to the dental team members and to other patients. Effective screening requires a thorough medical history of the patient and this medical history to be updated every visit. EMPLOYEE TRAINING All dental health care workers involved in the direct provision of patient care must undergo routine training in infection control, safety issues, and hazard communication. Training must encompass OSHAS pertinent regulations including blood borne pathogens standard. All new hires must receive training for at least 2 weeks before patient handling. 12 1. Immunization 2. Hygiene 3. Personal protective equipment(PPE)/ Barrier technique 08/18/15 13    HBV incidence in general population 1-2% in healthcare providers 10-30% ADA policy: all dentists and their staffs having patient contact should be vaccinated against HBV OSHA: employers should make HB vaccine available to occupationally exposed employees, at the employer’s expense within 10 working days of assignment of tasks that result in exposure 08/18/15 14 Vaccine Dose schedule Indications Influenza vaccine DHCP contact with patient at risk or work in chronic care. Measles, mumps, rubella vaccine Annual single-dose vaccination intramuscularly o.5ml dose S C. second dose after 4weeks Varicella- zooster vaccine 0.5 ml doses SC and after 4weeks DHCP - prolonged exposure to infectious co-worker or patient BCG vaccine Percutaneous dose of 0.3ml DCHP in multiple areas where multiple drug resistant TB, infection control precautions have failed DHCP, non immunized women of children, Chris miller, palenik. Infection control and management of hazardous material for the dental team, 3 rd edition        Followed hygienic measures greatly reduce the number of live pathogens Personal hygiene Refrain from touching anything, not required for the procedure Keep hands away from eyes, nose, mouth & hair Special attention for cuts, pimples, scratches etc. Hair away from face- head caps Jewellery Uniforms 16 GOAL OF INFECTION CONTROL 17 GOAL OF INFECTION CONTROL 1.To reduce the dose of microorganisms 2.minimize spraying or spattering of oral fluids 3.Hand washing and surface precleaning and disinfection 4.mouth masks, gloves, protective eye wear and clothing 5.Instrument precleaning and sterilization 18 SURGICAL SCRUB Surgical hand washing destroys transient organisms and reduces resident flora before surgical or invasive procedures .At the start of a session, an aqueous antiseptic detergent solution is applied to moistened hands and forearms for approximately 2 minutes.. The disinfection process must be thorough and systematic, covering all aspects of the hands and forearms. The procedure should take 3 to 5 minutes. Preparations currently available are 4% chlorhexidine and 7.5% povidone-iodine solution. The hands must be thoroughly dried with a sterile towel prior to donning sterile gloves. SURGICAL SCRUBS 19 Keeping nails short is considered key because the majority of flora on the hands are found under and around the fingernails Fingernails should be short enough to allow DHCP to thoroughly clean underneath them and prevent glove tears. Not more than 1/4inch long. Sharp nail edges or broken nails are also likely to increase glove failure. Long artificial or natural nails can make donning gloves more difficult and can cause gloves to tear more readily. Hand carriage of gramnegative organisms has been determined to be greater among wearers of artificial nails. Jewelry • Studies have demonstrated that skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings • Rings and decorative nail jewelry can make donning gloves more difficult and cause gloves to tear more readily . • Thus, jewelry should not interfere with glove use (e.g., impair ability to wear the correct-sized glove or alter glove integrity). STEPS IN PERFORMING SURGICAL SCRUB 22 HAND WASHING AND CARE OF HANDS 23 AN EFFECTIVE HAND WASHING TECHNIQUE INVOLVES THREE STAGES: 1. Preparation 2. Washing and Rinsing 3. Drying . 24 PREPARATIONS FOR PREOPERATIVE WASHING OF HANDS : 1.Hibiscrub & phisomed :- 4%chlorhexidine gluconate 2.Betadine :- contains 7.5% POVIDONE-IODINE 3.Soaps containing hexachlorophene 4.70%hibisol (2.5%chlorhexidine in 70%alcohol 25 PROTECTIVE ATTIRE AND BARRIER TECHNIQUES GLOVES FOR PROTECTION For protection of personnel and patients, gloves must be worn by the dentist when there is potential for contacting blood, blood contaminated saliva, or mucous membranes. Non sterile gloves are suitable for examinations and sterile gloves are suitable for any surgical procedures. Before treatment of each patient, dentist should wash their hands and put on a new gloves, and after treatment should discard the gloves and wash their hands. Surgical gloves should not be washed, disinfected, or sterilized for reuse USE OF GLOVES IN DENTISTRY 26 Note Washing latex gloves with plain soap, chlorhexidine, or alcohol can lead to the formation of glove micropunctures and subsequent hand contamination. Because this condition, known as wicking, can allow penetration of liquids through undetected holes, washing gloves is not recommended. DEGLOVING When gloves are torn, cut or punctured, they should be removed as soon as patient safety permits. Dentist then should wash their hands thoroughly and reglove to complete the dental procedure. Dentist who have exudative lesions or weeping dermatitis, particularly on the hands should refrain from all direct patient care and handling dental patient care equipment until the condition resolves. TYPES OF GLOVES IN DENTISTRY PATIENT CARE GLOVES STERILE LATEX SURGICAL GLOVES STERILE NEOPRINE SURGICAL GLOVES STERILE STYRENE GLOVES STERILE COPOLYMER GLOVES LATEX EXAMINATION GLOVES VINYL EXAMINATION GLOVES NITRILE EXAMINATION GLOVES POLYURETHANE GLOVES POWDERLESS GLOVES FLAVORED GLOVES LOWPROTEIN GLOVES UTILITY GLOVES •HEAVY LATEX GLOVES •HEAVY NITRILE GLOVES •THIN COPOLYMER GLOVES •THIN PLASTIC GLOVES OTHER GLOVES HEAT RESISTANT GLOVES DERMAL COTTON GLOVES 29 30 31 MASKS, FACE SHIELDS, EYE WEAR Chin length plastic face shields, surgical masks and protective eye wear should be worn when splashing or spattering of blood or other body fluids is likely to come in contact. When a mask is used it should be changed between patients or during patient treatment if it becomes moist or wet. Face shields and eye wear should be washed with a cleaning agent regularly. MASKS, FACESHIELDS, EYE WEAR 32 Impervious black paper, aluminum foil, plastic covers should be used to protect equipment and instruments that may become contaminated by blood or saliva during usage and are difficult to clean and disinfect. Once infected the coverings must be changed. 33 •Clinical sharps should be single-use only • Do not re-sheath a used needle • Discard sharps directly into a sharps container immediately after use • Carry sharps containers by the handle - do not hold them close to the body • Never leave sharps lying around • Do not try to retrieve items from a sharps container • Lock the container when it reaches the fill-line, using the closure mechanism • Place damaged sharps containers inside a larger sharps container 34 BIO AEROSOLS IN DENTAL OFFICE Bio aerosols are living microbes that travel via a mist and may contain bacteria, viruses, fungi or yeast. These air borne microorganisms can be found inside a dental office, coverings, surfaces etc. because aerosols are generally invisible, most individuals are unaware of their presence. Alginate powder mixed with water can become a aerosol and can cause bronchial irritation if inhaled. 35 Reduce contaminated aerosols  Distilled water rinse reduces bacterial aerosols by 75%  Brushing teeth before procedure- 90%  Mouth wash before procedure- 98%  Chlorhexidine gluconate(0.12%) mouth rinses effect a prolonged suppression of micro organisms.  36 STERILIZATION OF INSTRUMENTS IN DENTAL PRACTICE: Classification of instruments to be sterilized (spaulding classification) Critical  Surgical and other instruments that penetrate soft tissue or bone are classified as critical  Sterilized after each use Semi critical  Instruments do not penetrate soft tissue or bone but contact oral tissues are classified as semi critical.  Sterilized after each use but if not possible minimum high level disinfection for 6-10 hours needed. Non critical  Items that do not come in contact with body fluids, are called non-critical 37 Critical Extraction forceps Scalpels Bone chisels Scaling instruments Surgical burs Periosteal elevators Gingivectomy knife Bard parker handle Scissors Suction tips (metal) Suture needles Endodontic instruments Ultrasonic scaling tips Elevators/cross bars Semi-critical Mirrors Cheek/lip retractors Hand piece Tweezers restorative instruments Rubber dam equipment Saliva ejector/evacuator Polishing wheels and cups Non-critical Medicament jars Cavity liners Anaestheic spray tip Light cure tips Glass slab Cement spatula Instrument trays Orthodontic pliers Cotton dispensers Dapen dish Three way syringe tip Wax knife 38 SEMICRITICAL CRITICAL NON CRITICAL 39 Four stages of sterilization 1. 2. 3. 4. Pre sterilisation cleaning Packaging Sterilisation process Aseptic storage 40  Significance  Wear heavy duty gloves, eye protection and face mask while cleaning  Sharps be handled carefully 41 Be appropriate  Should allow penetration of steam to come in contact with all surfaces of instruments  Different types of packages  42 In dentistry sterilization is usually by 1)MOIST 2) HEAT.(STEAM UNDER PRESSURE) DRY HEAT(HOT AIR OVEN) 3)GASEOUS CHEMICALS. 43 44 Least expensive of all heat sterilizers  Spectrum  Its important to keep air spaces between instruments to ensure unform hot air distribution  45 ALCOHOLS  IODINE & IODOPHORS  CHLORINE AGENTS  PHENOL DERIVATIVES  ALDEHYDE  Chemical vapour sterilization.  The combinations of formaldehyde 0.2%, alcohols72.3%, acetone, ketones and steam at 138 kPa /20 psi serves as an effective sterilizing agent.  Microbial destruction results from the dual action of the toxic chemicals and heat.  It takes more time than autoclave but less time than hot-air oven that is 30 mins.  127 -132 c at 20 to 40 psi for a period of 30 minutes.  Instruments loosely packed  UNIVERSAL PRECAUTIONS 48 STANDARD PRINCIPLES OF INFECTION CONTROL/UNIVERSALPRECAUTIONS •Hand Hygiene and Skin Care •Protective Clothing •Safe Handling of Sharps (including Sharps Injury Management) •Spillage Management. •All blood and body fluids are potentially infectious, and precautions are necessary to prevent exposure to them. • A disposable apron and latex or vinyl gloves should always be worn when dealing with excreta, blood and body fluids. • Each member of staff is accountable for his/her actions and must follow safe practices. 49 OSHA FOR DENTISTRY •Require that universal precautions be observed to prevent contact with blood and other potentially infectious material. Saliva is considered to be blood contaminated body fluid in relation to dental treatments. •Provide hepatitis b immunization to employees without charge within 10 days of employment. •Implementing engineering controls to reduce production of contaminated mists and aerosols. •Implement work practice control precautions to minimize splashing or contact of bare hands with contaminated surfaces. •Provide facilities and instructions for washing hands after removing gloves and for washing skin immediately or as soon as feasible after contact with blood or potentially infectious materials. •Prescribe safe handling of needles and other sharp items. 50 •Contaminated sharps are termed as regulated waste and must be discarded in hard walled containers. •Contaminated equipment that has to be serviced must first be decontaminated or a bio hazard label must be put on it. • Do not try to retrieve items from a sharps container •Provide laundering of PPE to the employees without any cost. •Provide vaccination for all employees under no cost against all infectious that could be prevented by immunization. OSHA FOR DENTISTRY PROVIDING A HELPING HAND ALWAYS 51 •Prescribe disposable or single use needles, sharps and dispose them as soon as feasible in a hard walled leak proof containers that are closable. Containers must bear a biohazard label. Teeth must be discarded into sharp containers. •Contaminated reusable sharp instruments must not be stored •Prohibit eating, drinking, handling contact lenses etc in contaminated environments. Ban storage of foods and drinks in refrigeration or other spaces where blood or infectious materials are stored. •Place blood and contaminated specimen to be transported into a suitable closed container that prevents leakage. •Provide PPE to employees and clear directions for use of universal precautions. Ensure the correct use of PPE. •As soon as feasible the working surface and environment must be sanitized after treatment. Provide a written schedule for cleaning. 52  Clinical contact surfaces ◦ High potential for direct contamination from spray or spatter or by contact with DHCP’s gloved hand  Housekeeping surfaces ◦ Do not come into contact with patients or devices ◦ Limited risk of disease transmission 53 54 55 Micro organisms that accumulate on surfaces inside moist environments such as dental unit water lines, allowing bacteria, fungi, and viruses to multiply  Composed of millions of micro organisms that accumulate on surfaces in aqueous environments  Excrete glue like substance that anchors them to substrate and forms a slimy protective layer which renders them resistant to disinfectants  56 … Waterline bio-films contd  Organisms found- mature biofilms that vary in the type of organisms inhabiting them Bacteria- Actinomyces, Acinetobacter, Bacteroides, Fusobacterium, Lactobacillus, Legionella, Pasteurella, Staphylococcus, Streptococcus, etc.  Fungi- Penicillium, Cladosporium, Alternaria, etc.  Protozoa- Acanthamoeba, Cryptosporidium  57 ADA- no more than 200 cfu/ml of bacteria CDC recommends  Flush air & water through hand pieces for 20 sec between patients  Avoid using dental unit water for procedures involving bone cutting  Minimize usage of water  58 1. Improve quality of incoming water 2. Control biofilms in reservoirs and tubings 3. Control water quality as it leaves the tubing 59  Avoid using water from public water supply  For irrigation, use a hand syringe filled with either sterile water or distilled water 60       Decontaminate or disinfect the reservoirs / water lines routinely Disposable lines with a sterile water supply Reservoirs as small as possible- no stagnation of water for longer time Disinfection1 part house hold bleach (5.25% Sodium hypochlorite) + 9 parts water 100 ml solution in to the bottle- cap the bottle- shake for 5sec- wait 10 min- shake bottle again- empty bottle- rinse bottle twice with treatment water 61 STERILISATION IN OPERATING ROOM FUMIGATION OF OPERATING ROOM Fumigation can be achieved by fumigators Fumigation is done with the instrument STERITRAX Fumigation chemical used is 40% FORMALINE Fumigator is set for 30 mins with timer adjustments in the instruments 62 A FOMITE is defined as an object, which becomes contaminated with infected organisms and which subsequently transmits those organisms to another person. Examples of potential FOMITES are instruments, impression trays and suction tips. FOMITES IN DENTAL CLINIC 63 DISEASE THAT WE MUST BE AWARE OF……… HEPATITIS HIV TUBERCULOSIS HERPES CANDIDIASIS 64 • Blood borne pathogens are contained in the blood and other body fluids and the disease may spread from person to person through contact with body fluids. •pathogens may enter the mouth through dental procedures that induce bleeding 65  Blood borne 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  Only one documented case of HIV transmission from an infected dentist to patients  No transmissions documented in the investigation of 63 HIVinfected HCP (including 33 dentists or dental students)  Reported frequency among general dentists has declined  Caused by burs, syringe needles, other sharps  Occur outside the patient’s mouth  Among oral surgeons, occur more frequently during fracture reductions and procedures involving wire Engineering controls Personal protective equipment Work practice controls Isolate or remove the hazard from the worker  Examples:  ◦ Sharps container ◦ Medical devices with injury protection features (e.g., self-sheathing needles and scalpel blades)  Safer Design  Change the manner of performing tasks  Examples include: ◦ Using instruments ◦ One-handed needle recapping prevent the transmission of blood borne pathogens following a potential exposure to HIV NACO Guidelines for ART, May 2007 NACO Guidelines for ART, May 2007 NACO Guidelines for ART, May 2007 Not Recommended if: •Exposed person already HIV positive •Exposure occurred more than 72 hrs. ago •Exposure does not present risk •Skin is intact •Fluid is non infectious •Source is known to be HIV negative NACO Guidelines for ART, May 2007 Recommended if: •Exposed person is HIV negative •Exposure occurred within past 72 hrs. •Source is HIV infected/ unknown status •Significant exposure to infectious fluid •Skin is non intact/ punctured •Mucous membrane exposed NACO Guidelines for ART, May 2007 Basic regimen Zidovudine 300mg + Lamivudine 150mg Twice daily for 4weeks Expanded regimen Lopinavir 2000Mg+ Ritonavir 50Mg Atazanavir 300Mg +Ritonavir 100Mg Zidovudine300mg+ Lamivudine 150mg +indanavir 800mg – 2 Tab. BD or 4 Tab. OD Thrice daily for 4weeks  sexually active adults at risk for HIV infection FDA approved regimen  Tenofovir disoproxil fumarate 300mg plus emtricitabine 200mg  Most of oral and maxillofacial radiology consists of non invasive procedures  Oral and maxillofacial radiology procedures fall mainly in the semi critical and noncritical categories of Spaulding's classification  It is advisable to use PPE when treating patients with history of gag-reflex or spatter is expected Charles john, infection control for dental radiography, 2004 AADMRT Charles john, infection control for dental radiography, 2004 AADMRT Cover film with plastic barrier Remove film packet avoiding contamination of the film. Handle clean film with new gloves. Charles john, infection control for dental radiography, 2004 AADMRT  Barrier Protection  Regloving  Two- Person Technique Charles john, infection control for dental radiography, 2004 AADMRT Charles john, infection control for dental radiography, 2004 AADMRT 3- adjust x-ray tube and controls with clean gloves 1- Position film in patient’s mouth 2- Change gloves 4- Remove the film from the mouth 5- Remove film from wrapper. 6- discard used gloves and outer film wrapping. Another person wearing clean gloves adjusting x-ray tube and control One person placing film in patient’s mouth The person with the dirty gloves then removes the film from the packet without contaminating the film Impressions, casts, bite-registration blocks and dentures must be disinfected Immersion in 1% sodium hypochlorite for 10 minutes   There should be no residual germicides  Veneers, porcelain, must be sterilized  Considerations for extracted teeth Methods to decontaminate teeth - heat sterilization - immersion in sterilants such as 5000 ppm bleach 7% hydrogen peroxide 2 %Gluteraldehyde a) If the teeth is to be used to preclinical lab or for research purposes - immerse in 0.005% thymol solution in water COLOUR CODING TYPE OF CONTAINER WASTE CATEGORY TREATMENT OPTIONS Plastic bag •Microbiology and bio technology waste •Solid waste containing blood and other body fluids Blood soaked cotton , gloves Incineration/deep burial Disinfected container/plastic bag •Microbiology and bio technology waste •Solid waste containing blood and other body fluids •Solid waste from disposables other than sharps like suction tips Autoclaving/microwaving/chem ical treatment Plastic bag/puncture proof container •Waste sharps used/unused, syringes, Bpblade, discarded sharp instuments, punch biopsy forceps Autoclaving/microwaving/chem ical treatment and destruction/shredding Plastic bag •Discarded medicines and cytotoxic drugs, •Incineration ash, •Chemicals used in disinfection, insecticides . Disposal in secured landfill Yellow Red Blue/white BLACK 88           Cdd, guidelines for infection control in dental health-care settings --december 19, 2003 / 52(rr17);1-61 Charles john, infection control for dental radiography, 2004 AADMRT Personal protective equipment , OSHA 3151-12R 2003 Http://www.Cdc.Gov/oralhealth/infectioncontrol/guidelines/index.Htm Www.Nacoonline.Org Burket’s medicine, 11th edition Textbook of oral and maxillofacial surgery by neelima anil malik, dr., Malik Chris h.Miller ;infection control and management of hazardous materials for the dental team, 3rd edition Cottones ; preactical infection control in dentistry, 3rd edition textbook of microbiology, ananthnarayan and paniker Oral Radiology –: Stuart C White, Michael J Pharoah ; 6th edition