CONSISTENT PRACTICE PROTOCOLS CAN BREAK THE

CHAIN OF INFECTION

By

MANISH GOUTAM

IIIrd yearPEOPLE’S COLLEGE OF DENTAL SCIENCES &

RESEARCH CENTRE ,BHOPAL

CHAIN OF INFECTION

INTRODUCTIONWHY DO WE NEED TO KNOW ABOUT INFECTION CONTROL ?

THE GOAL OF INFECTION CONTROL IS TO ELIMINATE OR REDUCE THE NUMBER OF MICROBES SHARED BETWEEN PEOPLE.

IMPLEMENTING SAFE AND REALISTIC INFECTION CONTROL PROCEDURES REQUIRES THE FULL COMPLIANCE OF THE WHOLE DENTAL TEAM.

Infection control in dentistry¤ Training regarding infection control¤ Surgery design¤ Choice of equipment¤ Decontamination of instruments and equipment¤ Single use (disposable) items¤ Surface cleaning and disinfection¤ Decontamination of instruments and equipment prior to service or repair¤ Decontamination of impression materials andprosthetic and orthodontic appliances¤ Disposal of clinical waste¤ Blood spillages¤ Biopsy specimens sent through the post

¤ Immunization¤ Hand protection by gloves¤ Eye protection and face masks¤ Surgery clothing¤ Aerosol and saliva/blood splatter¤ preventing Inoculation injuries

PERSONAL PROTECTION

Blood borne Pathogens¤ Preventing Transmission of Blood Borne Pathogens¤ Hepatitis B Virus¤ Hepatitis D Virus¤ Hepatitis C Virus¤ Human Immunodeficiency Virus¤PRE Exposure Prevention Methods¤ Postexposure Management and Prophylaxis

Concept of Infection

The number of organisms required to cause an infection is termed as “The infective dose”.

General Principles

Universal precautions – use of mouth mask, head cap, protective eye were gloves are recommended.

Hand washing and care of hands

Sir William Osler once remarked that Soap and water and common sense are the best disinfectants.

Use of commonly available antiseptic hand wash like chlorhexidine is generally enough.

OSHA (Occupational safety and Health agency) regulation:-•Blood borne Pathogens Exposure Control including Biohazard Waste•Management Protocol•Hand Hygiene•Use of Personnel Protective Equipment•Issues regardingLatex/Hypersensitivity/ Contact Dermatitis•Sterilization and Disinfection•Environmental Infection Control•Efficient  and Clean Use of Dental Unit Waterlines

•Ventilation – The recommended fresh air supply rate of ventilation systems should not fall below 5-8 liters per second per occupant.

Recycling air conditioning systems are not recommended.

•Floor Covering

The floor covering should be impervious and non slippery.

Carpet must be avoided.

ENVIRONMENT OF DENTAL OFFICE

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 and some time they even don’t know that he is infected.

AIR BORNE CONTAMINATION

Immunization - Hepatitis B infection

Anti – HBs levels must be measured 2-4 months after complete immunization course.

HBS level > 100 M/U/ml will provided adequate protection.

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

PERSONAL RISK

Infections diseases of concern in dentistry.

Bacteria Viruses

N.Gonorrhoeae Hepatitis B,C,D

T. Pallidum H.I.V.

M. Tuberculosis Cytomegalo virus

Strep. Pyogenes Measles

Mumps

Rubella

Herpes

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.

METHODS OF INFECTION CONTROL

Choice of equipments depends upon the requirement of the practitioners.

Water supplies

The ADA council on scientific affairs recommends to improve the design of dental equipment of that water delivered to patients during non surgical dental procedures it should contains no more than 200 colony forming units / ml (cfu/ml) of bacteria at any point of time in the unfiltered output of dental unit.

CHOICE OF EQUIPMENTS

Bio-films of vegatitive form of bacterias spores and the organic matter formed on the surface of the instrument have to be washed with the suitable disinfectant before proceeding with the sterilization process.

PRE-STERILIZATION CLEANING

Physical agents

Heat – Moist, Dry

Ionizing radiations

X-rays, beta rays

gamma rays

Ultraviolet rays

Filtration

Chemical agents

Agents acting on cell membrane

Surface acting agents, Phenols, Organic solvents

Agents that denature proteins

Acids and alkalies

Agents acting on functional group of proteins

Heavy metals

Oxidizing agents, Dyes, Alkylating agents.

STERILIZATION

Steam Pressure Sterilization (Autoclaving)

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 % sodium nitrite sol.

AUTOCLAVE

Dry Heat Sterilization – Hot air oven

Dry heat at 160 degree Celsius is commonly used for this purpose. Microbial inactivation by dry heat is primarily an oxidation process.

Employed for sterilization of glassware, glass syringes, oily injection as well as metal instruments.

Chemiclaving – Using ethylene oxide gas

131 degree celsius 20 pounds pressure is use for this purpose. Heat sensitive plastic instrument are sterilized by this method.

•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.

NEW METHODS OF STERILIZATION

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. – done by dipping them in 2 % gluteraldehyde solution for minimum of 2 hours.

These should be wrapped in sterile bag.

TYPES OF INSTRUMENTS AND STERILIZATION METHODS.

classification

WASTE MANAGEMENT

Classification and managementCategory Waste Type Treatment and Disposal Method

Category 1

Human Wastes (Tissues, organs, body parts

Incineration / deep burial

Category 2 Animal Waste Incineration / deep burial

Category 3

Microbiology & Biotechnology waste

Autoclave/microwave/incineration

Category 4 Sharps

Disinfection (chemical treatment)+autoclaving/microwaving .

Category 5

Discarded Medicines and Cytotoxic Drugs

Incineration/ destruction and drugs disposal in secured landfills

Category Waste Type Treatment and Disposal Method

Category 6 Contaminated solid waste

Incineration/autoclaving / microwaving

Category 7

Solid waste (disposable items other than sharps)

Disinfection by chemical treatment+ microwaving/autoclaving

Category 8

Liquid waste (generated from laboratory washing, cleaning, housekeeping and disinfecting activity)

Disinfection by chemical treatment+ and discharge into the drains

Category 9 Incineration ash Disposal in municipal landfill

Category10 Chemical Wastes

Chemical Treatment + and discharge in to drain for liquids and secured landfill for solids

ManagementColor coding Type of container

Waste category treatment option

YELLOW PLASTIC

BAGCat 1,2,3,6 Incineration /

deep burial

RED Disinfected container / plastic bag

Cat 3,6,7 Autoclave/microwave /chemical treatment

Blue/white translucent

Plastic bag/ Puncture proof

Cat 4,7 Autoclave/microwave /chemical treatment /

destruction shredding

BLACK Plastic bag

Cat 5,9,10 Disposal in secure

landfill

 

1.   FIRST AIDo         Contaminated Wound - Encourage bleeding from the skin wound and wash the injured area with copious soapy water, disinfectant, scrub solution or water.o         Contaminated Intact Skin - Wash the area with soap and water.o         Contaminated Eyes -   Gently rinse the eyes while open with Saline or water.o         Contaminated Mouth -  Spit out any fluid - rinse the mouth with water and spit out again. 2.   REPORT ACCIDENT 

PROTOCOL TO BE FOLLOWED AFTER A NEEDLESTICK INJURY OR BLOOD/BODY FLUID EXPOSURE. 

4.   IMMEDIATE ACTION•   If the patient is known to be HIV positive then the exposed Health Care Worker should be given counseling and offered Post exposure prophylaxis (PEP).  HIV post exposure chemoprophylaxis for health workers.

Basic (28 days) – Zidovudine + Lamivudine

Expanded (28 days) – As above + Indinavir or nelfinavir or neviriapine•General Practitoner need to know where they can access the PEP drugs as they should be given within 72 hours following exposure. 

5.   FURTHER ACTION•    If status of Patient and Health Care Worker is unknown and immune status can’t be obtained within  48 hours then give:-

(a) Hepatitis B. Immune Globulin

(b) Hepatitis B. Vaccine (first dose). •If the Health Care Worker is HBV immune then no further Hep B Vaccine is required. Check Hep B antibody titre of health care worker and if low give Hepatitis B booster.•Give Tetanus Toxoid booster if indicated. 6.   FOLLOW UP

i.     complete the course of Hepatitis Vaccine.

ii.    follow up HIV serology 1, 3 months  and 6 months.

CDC, Division of Healthcare Quality Promotion http://www.cdc.gov/ncidod/hip

CDC, Division of Oral Health, Infection Control http://www.cdc.gov/OralHealth/infectioncontrol/index.htm

CDC Recommends, Prevention Guidelines System http://www.phppo.cdc.gov/cdcRecommends/AdvSearchV.asp

OSHA, Dentistry, Bloodborne Pathogens http://www.osha.gov/SLTC/dentistry/index.html 

http://www.osha.gov/SLTC/bloodbornepathogens/index.htmlOrganization for Safety and Asepsis Procedures 

http://www.osap.org

Infection-Control Internet Resources