Why is infection control important in dentistry?

1. Both Patients and dental health care personnel (DHCP) can be

exposed to pathogens.

2. Contact with blood, oral and respiratory secretions, and

contaminated equipment occurs.

3. Proper procedures can prevent transmission of infections among

patients and DHCP.

Modes and Routes of Transmission

Mode of transmission

1. Direct contact with blood or body fluids.

2. Indirect contact with a contaminated instrument or surface.

3. Contact of the eye, nose, or mouth with droplets or spatter.

4. Inhalation of airborne microorganisms.

Potential routes of transmission of blood borne pathogens

1. Patient → DHCP

2. DHCP → Patient

3. Patient → Patient
Blood-borne Viruses & Needle-stick Risk

Blood borne viruses

Such as hepatitis B Virus (HBV), hepatitis C virus (HCV), and human

immunodeficiency virus (HIV)

1. Are transmissible in health care settings.

2. Can produce chronic infection.

3. Are often carried by persons unaware of their infection.

Average risk of blood borne virus transmission after needle stick

HBAg

1.0%–6.0% clinical hepatitis

23%–37% serological evidence of HBV infection

HCV

1.8% (0%–7% range)

HIV

0.3% (0.2%–0.5% range)

Concentration of HBV in body fluid

• High ➔ blood

• Moderate ➔ Semen – vaginal fluid – Saliva

• Low or not detectable

1. Urine

2. Feces

3. Sweat

4. Tears

5. Breast milk

Universal Protocol & Personnel Health

Universal protocol of infection control

Personnel health elements

• Education and training

• Immunization

• Medical health

Standard precautions

• Hand hygiene

• Barrier technique

• Prevention of injury
Sterilization and disinfection

• Patient care equipment

• Environmental surfaces

Hepatitis B Vaccine (Immunization)

1. Vaccinate all DHCP who are at risk of exposure to blood.

2. Provide access to qualified health care professionals for

administration and follow-up testing.

3. Test for anti-HBs 1 to 2 months after 3rd dose.

Standard Precautions (Core Concept)

• Must be applied 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 and mucous membranes are critical fields.

Elements of standard precautions

• Hand washing.

• Use of gloves, masks, eye protection, and gowns.

• Injury prevention.
Hand Hygiene

Why is hand hygiene important?

1. Hands ➔ most common mode of pathogen transmission.

2. Reduce spread of antimicrobial resistance.

3. Prevent health care associated infections.

Hands need to be cleaned when

• Visibly dirty → Hand washing.

• After touching contaminated objects with bare hands.

• Before and after patient treatment

(before glove placement and after glove removal).

Hand hygiene definitions

Hand washing

Washing hands with plain soap and water.

Antiseptic hand wash

Washing hands with water and soap or other detergents containing an

antiseptic agent.

Alcohol–based hand rub

Rubbing hands with an alcohol-containing preparation.

Surgical antisepsis

Hand washing with an antiseptic soap or an alcohol-based hand rub before

operations by surgical personnel.

Special hand hygiene considerations

1. Use hand lotion to prevent skin dryness.

2. Consider compatibility of hand care products with gloves

3. (e.g. mineral oils and petroleum base may cause early glove failure)

4. Keep fingernails short

5. Avoid artificial nails

Barrier Technique & Personal Protective Equipment

Personal protective equipment (PPE)

• 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 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

Gloves

• Minimize risk of health care personnel acquiring infections from

patients

• Prevent microbial flora from being transmitted from health care

personnel to patients.

• Reduce contamination of hands of health care personnel by microbial

flora that can be transmitted from 1 patient to another.

• Not substitute for hand washing

Recommendations for gloving

1. Wear gloves when contact with blood, saliva, and mucous

membranes is possible.

2. Remove gloves after patient care

3. Wear new pair of gloves for each patient.

4. Remove gloves that are torn, cut, or punctured

5. Don’t wash, disinfect, or sterilize gloves for reuse

Latex Hypersensitivity & Contact Dermatitis

Latex allergy

• Type 1 hypersensitivity to natural rubber latex proteins.

• Reactions may include nose, eye, and skin reactions.

• More serious reactions may include respiratory distress – rarely shock

or death.

Contact dermatitis

Irritant contact dermatitis

1. Not an allergy
2. Dry, itchy, irritated areas
Prevention of Injuries (Sharps Management)

• Sharp items containers

• Education & working principles

• Work practice controls

• Change manner of performing tasks

o Using instruments instead of fingers to retract tissue.

o 1-handed needle recapping.

Characteristics of percutaneous injury among DHCP

• Reported frequency among general dentists has declined.

• Caused by burs, syringe needles, other sharp instruments.

• Occur outside the patient’s mouth

• Involve small amounts of blood

• Among oral surgeons, occur more frequently during fracture

reduction and procedures involving wire.
Post-exposure Management

1. Wound management

2. Exposure reporting

3. Assessment of infection risk:

• Type and severity of exposure.

• Blood borne status of source person.

• Susceptibility of exposed person.

Disinfection & Sterilization of Patient Care Items

What is disinfection?

Process whereby most of organisms that cause disease are killed by

chemical agents

What is sterilization?

• Ultimate process to destroy all living microorganisms, including spores

(reproductive bodies) of hardiest bacteria and fungi.
• This process facilitated by initial removal of material by cleaning and use
of an ultrasonic device.

Cold sterilization

• For items that would be damaged by high heat involved in other

sterilization processes, a non-heated liquid sterilization procedure used.
• This involves soaking contaminated object in chemical solution, such as
glutaraldehyde, for about 10 hours
Patient Care Equipment – Instrument Categories

Dental instruments may be classified as

1 – Disposable

2 – Reusable

1. Critical instruments

• Penetrate mucous membranes or contact bone, bloodstream, or

other normally sterile tissues (of the mouth).

• Heat sterilize between uses or use sterile single-use disposable

devices.

• Examples: surgical instruments, scalpel blades, periodontal scalers,

surgical dental burs.

2. Semi-critical instruments

• Contact mucous membranes but do not penetrate soft tissue.

• Heat sterilize or high-level disinfect

• Examples: dental mouth mirrors, amalgam condensers, dental

handpieces.

3. Non-critical 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.

Instrument Processing Area & Cleaning

Instrument processing area

Use designated processing area to control quality and ensure safety.

Divide processing area into work areas

1. Receiving, cleaning, and decontamination.

2. Sterilization

3. Preparation and packing

4. Storage

Goals

• Decrease infectious microbes on instruments which cannot be

cleaned and sterilized immediately.

• Loosen and minimize debris before scrubbing or ultrasonic cleaning.

• Minimize the physical handling of the instruments.

Automated Cleaning

1. Ultrasonic cleaner

2. Instrument washer

3. Washer-disinfecton

Manual cleaning

• Soak until ready to clean.

• Wear heavy-duty utility gloves, mask, eyewear, and protective clothing.
Preparation, Packaging & Heat-based Sterilization

Preparation and packaging

• Critical and semi-critical items that will be stored should be wrapped

or placed in containers before sterilization.

• Hinged instruments opened and unlocked.

• Place chemical indicator inside pack.

• Wear heavy-duty, puncture-resistant utility gloves.

Heat-based sterilization

1. Autoclaving ➔ steam under pressure

• Gravity displacement

• Pre-vacuum

2. Dry heat

Disadvantages of dry heat

1. Cool spot.

2. Time

3. Not suitable for plastic instruments.

Liquid Chemical Sterilants / Disinfectants

1. Only for heat-sensitive critical and semi-critical devices.

2. Powerful, toxic chemicals raise concerns.

3. Heat tolerant or disposable alternatives are available.

Sterilization Monitoring

Types of Indicators

1. Mechanical

Measure time, temperature, pressure.

2. Chemical

Change in color when physical parameter is reached.

3. Biological (spore tests)

Use biological spores to assess the sterilization process directly.

Storage of Sterile and Clean Items

• Use date-or event-related shelf-life practices.

• Examine wrapped items carefully prior to use.

• When packaging of sterile items is damaged, re-clean, re-wrap and

re-sterilize.

• Store clean items in dry, closed or covered containment

Care of Handpiece

1. Autoclave at 135°C

2. Do not use glutaraldehyde, bleach, chlorine dioxide.

3. Flush water line

4. Cleanse submerged with scrub brush

5. Wrap in gauze

6. Place in sealed bag 10 minutes; rinse and dry.

7. Anti-retraction valve.
Environmental Infection Control

Environmental surface

1. May become contaminated.

2. Not directly involved in infectious disease transmission.

3. Don’t require as stringent decontamination procedures.

Categories of environmental surface

Clinical contact surface

High potential for direct contamination from spray or spatter or by contact

with DHCP’s.

Housekeeping surface

• Do not come into contact with patients or devices.

• Limited risk of disease transmission.

Cleaning & Disinfection of Surfaces

General cleaning recommendations

• Use barrier precautions

(e.g., heavy-duty utility gloves, masks, protective eyewear) when

cleaning and disinfecting environmental surfaces.

• Physical removal of microorganisms by cleaning is as important as

disinfection process.

• Follow manufacturer’s instructions for proper use of EPA-registered

hospital disinfectants.

Cleaning clinical contact surfaces

• Risk of transmitting infections greater than for housekeeping surfaces.

• Surface barriers can be used and changed between patients.

OR

Clean using an EPA-registered low-level (HIV/HBV claim) to intermediate-

level (tuberculocidal claim) hospital disinfectant.

Cleaning housekeeping surfaces

• Routinely clean with soap and water or an EPA-registered

detergent/hospital disinfectant.

• Clean mops and cloths and allow to dry thoroughly before re-using.

• Prepare fresh cleaning and disinfecting solutions daily and per

manufacturer recommendations.
Infection Control Protocol for Surfaces & Equipment

Each morning

1. Flush water lines 3 minutes

2. Disinfect surfaces and equipment (SteriWise surface disinfectant).

Between patients

1. Flush waterlines 15 seconds.

2. Disinfect handpieces, 3-way syringes, evacuators.

3. Remove disposable covers.

4. Disinfect "high touch" areas.

At the end of each day

1. Flush water lines 3 minutes.

2. Disinfect vacuum system (SteriWise disinfection suction cleaner).

3. Disinfect equipment.

4. Disinfect surfaces and floors.

Weekly

1. Disinfect inside drawers and cabinets.

2. Disinfect floors of operatory, darkroom, laboratory.

3. Clean and replace solids collector trap.

Medical Waste

Regulated medical waste management

• Properly labeled containment to prevent injuries and leakage.

• Medical wastes are “treated” in accordance with state and local EPA
regulations

• Processes for regulated waste.

• Medical waste container

Infection Control in the Dental Lab

• Potential for disease transmission in the dental lab is well

documented.

• Potential pathogens can be transported to lab via orally soiled

impressions, dental prostheses/appliances.

• Microorganisms can be transferred from contaminated impressions

to dental casts.

• Oral bacteria can remain viable in set gypsum for up to 7 days.

Lab personnel may be exposed via

• Direct contact (through cuts and abrasions).

• Aerosols created during lab procedures (inhaled or ingested).

Patients can be at risk due to

• Potential cross-contamination between dental prostheses/appliances.

• Potential for cross-contamination from dental office to lab and back.

Dental Laboratory Items & Chemical Disinfectants

Chemical disinfectants – functions

• Must be an effective antimicrobial agent.

• Must not adversely affect dimensional accuracy or surface texture of

impression materials and resulting gypsum cast.

Chemical Disinfectants – requirements

• All employees must be properly trained to handle these materials.

• Disinfectant must have an Environmental Protection Agency (EPA)

registration number.

• Must have at least intermediate-level of activity.

Tuberculocidal, hospital-grade

• Strictly follow manufacturer instructions.

Incoming items

• Rinse under running tap water to remove blood/saliva.

• Disinfect as appropriate.

• Rinse thoroughly with tap water to remove residual disinfectant.

• No single disinfectant is ideal or compatible with all items.

Outgoing items

• Clean and disinfect before delivery to patient.

• After disinfection: rinse and place in plastic bag with diluted

mouthwash until insertion.

• Do not store in disinfectant before insertion.

• Label the plastic bag

“This case shipment has been disinfected with ______ for _____ minutes”