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part 2 : Infection control

Rouby Daoud Layla Abu-Nabaa 4-7-2013

Prosthodontics Lecture 2 Part 2

Infection control in Prosthodontics clinic

* not all of the slides are required, slides (1-5,11,19-26,92-108) are not required as the doctor mentioned in the lecture. You as a dentist have to know cross infection control : -Both patients and dental health care personnel (DHCP) can be exposed to pathogens -Contact with blood, oral and respiratory secretions, and contaminated equipment occurs. Look at what you are dealing with,what if saliva was red and you can see it, you are putting your hand into the patients mouth,its red, its all over the patients face,instruments,hands.saliva is an infectious material,this is why we need to protect ourselves.
(see video)- http://www.youtube.com/watch?v=nImdNED6nHA

The second reason why we need to protect ourselves is because we surround ourselves with these droplets of water going out of the instruments,they are carrying with them all of the microorganisms that are present in the patients mouth because first you put in their mouth,it hits the mouth and goes back,so this is what you are surrounded with, all types of microorganisms from the saliva as well as from the aerosols. The doctor mentioned a video on youtube that she couldnt find,and said its beneficial to see.in the video,they have put a green marker in the saliva and all of the liquid materials they are using including the liquids in the handpieces,and they let the dentist work as usual,then they made the video just with a detector of the color green,this video shows the dentist surrounded by a cloud of aerosols produced from the patients mouth and the handpieces hes using,this is why its important for you as a dentist to get the infection control needed.

Modes of Transmission : 1-Direct contact with blood or body fluids 2-Indirect contact with a contaminated instrument or surface 3-Contact of mucosa of the eyes, nose, or mouth with droplets or spatter 4-Inhalation of airborne microorganisms Both you and your patient are at risk thats why your standards should apply to all patients not to diseased people only,because not all patients know that they are infected. Do you know that the percentage of hepatitis B in Jordan might reach 1020% depending on the area,and its higher in Egypt and other Mediterranean countries, which means that 1 out of 10 of your patients has hepatitis B and might not know about it, so dont blame the patients for not knowing. So make sure you apply all of these precautions to every patient no matter what his status is. So the basic things we are : (Elements of Standard Precautions) Handwashing Use of gloves, masks, eye protection, and gowns (labcoats) Patient care equipment Environmental surfaces Injury prevention

Personnel Health Elements of an Infection Control Program This is the responsibility of any institute youre going to work in as a dentist, They should give you : Education and training Immunizations (hepatitis B vaccine for example) Exposure prevention and postexposure management Medical condition management and work-related illnesses and restrictions Health record maintenance

There are pathogens we are afraid of (hepatitis C,hepatitis B,HIV) and these are common,are transmissible in health care settings, Can produce chronic infection and are often carried by persons unaware of their infection Potential Routes of Transmission of Bloodborne Pathogens 1-patient to DHCP (dental health care personnel) 2-DHCP to patient 3-patient to patient Factors Influencing Occupational Risk of Bloodborne Virus Infection 1- Frequency of infection among patients 2- Risk of transmission after a blood exposure (i.e., type of virus) 3- Type and frequency of blood contact Slide 17 (numbers are not required) When the percentage for Hepatitis B is 22-31% in some countries that means that almost in every 3 patients,1 has hepatitis B,these are not our numbers thats why I dont want you to memorize them.As for Hepatitis C in every 50 patients 2 of them have it,and most of them dont know,and those that know will not tell you because they have been refused to treatment by maybe 10 doctors before you.HIV,0.03% which means 3 out of a thousand patients have HIV. What transmits diseases more? Blood and serum,and you are dealing with blood everyday,sometimes just probing to the patient can cause bleeding from the gingiva,or doing scaling it might also cause bleeding,or when you do an injection. Diseases are less transmitted through semen,vaginal fluid and saliva. The non detectable routs of transmission are urine,feces,breast milk,tears and sweat. So what you are dealing with in your clinic are blood and saliva.

Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected Blood: 1-Deep injury 2-Visible blood on device 3- Needle placed in artery or vein 4- Terminal illness in source patient

Characteristics of Percutaneous Injuries Among DHCP Reported frequency among general dentists has declined Caused by burs, syringe needles, other sharps Occur outside the patients mouth Involve small amounts of blood Among oral surgeons, occur more frequently during fracture reductions and procedures involving wire

How do I prevent it?? (Exposure Prevention Strategies) 1- Engineering controls Isolate or remove the hazard,for example: sharps container,medical devices with injury protection features,like self-sheathing needles (as the doctor explained,when you try to put back the cover of the needle, if somehow you put it in the wrong direction,the needle will hit a small card attached to the cover instead of your finger,thus preventing injury) *the most common finger injury happens when trying to put back the cover of the needle after giving an injection which in some cases will cause transmission of certain diseases. 2- Work practice controls Change the manner of performing tasks,for example: using instruments instead of fingers to retract or palpate,one-handed needle recapping (allows to put the cover back on the needle using one hand only) 3- Administrative controls Policies, procedures, and enforcement measures Placement in the hierarchy varies by the problem being addressed Placed before engineering controls for airborne precautions (e.g., TB)

So suppose you got an exposure,suppose the nurse came and said she had a needle stick form the patient you had inside,and it turned out that that patient for example has Hepatitis! what will you do for the nurse or yourself if you had an exposure,it could be a needle stick or a bur that hurt your hand or a blade while cutting the gingiva or even if the patient bit your hand if he was in pain and you bleed in his mouth,all of these are called exposures and this is real,this is why we insist when you do a preparation to always have a finger rest to control your hand and not let it slip away because you might by the bur injure the cheek or the lip of the patient which will cause continuous bleeding,so any direct contant with any of these infectious materials is called an exposure. There should be policies and procedures,there are recommendations you will take them later on when you go to the clinics but in general they include : Post-exposure Management Program 1-Clear policies and procedures 2-Education of dental health care personnel (DHCP) 3-Rapid access to Clinical care (going to a doctor) Post-exposure prophylaxis (PEP) Testing of source patients/HCP (take a blood sample to make sure if they have a disease) because its not a procedure only for your nurse,but for the patient as well. Post-exposure Management Now if the patient turned out to have the disease there are other things to do later on,but in general you do : 1-Wound management (keep squeezing the wound itself to let anything that went in,go out) 2-Exposure reporting (write it down on paper and report it to the hospital or wherever the place you are working in) 3-Assessment of infection risk Type and severity of exposure

 Bloodborne status of source person (do a blood test for the patient) Susceptibility of exposed person

Hand Hygiene What is the most frequent thing that dentists do? They wash their hands! Right after everything they do,they wash their hands,in time it becomes a habit! So,Why Is Hand Hygiene Important? Hands are the most common mode of pathogen transmission Reduce spread of antimicrobial resistance Prevent health care-associated infections

Hands Need to be Cleaned When Visibly dirty After touching contaminated objects with bare hands Before and after patient treatment (before glove placement and after glove removal) Hand Hygiene Definitions And this is very important and you have to know the difference between each and everyone of them. Handwashing Washing hands with plain soap and water Antiseptic handwash Washing hands with water and soap or other detergents containing an antiseptic agent (it kills germs,for example dettol) Alcohol-based handrub Rubbing hands with an alcohol-containing preparation (hygiene) Surgical antisepsis

 Handwashing with an antiseptic soap or an alcohol-based handrub before operations by surgical personnel (more power anti microbial agent like iodine).its used by surgeons when they are preparing to do a surgery where they clean their hands up to the elbows,using a special brush then place iodine over their hands,rinse it with tap water,go into the surgery room without letting their hands touch the door then finally wearing gloves.so this is done when you are doing a type of surgery inside your clinic such as periodontal surgery or implants. As for the Efficacy of hand hygiene preparations, the more you clean and the more antiseptic material you put is always the best. Special Hand Hygiene Considerations (Especially for females ) Use hand lotions to prevent skin dryness Consider compatibility of hand care products with gloves (e.g., mineral oils and petroleum bases may cause early glove failure) Keep fingernails short Avoid artificial nails Avoid hand jewelry that may tear gloves Long nails,nail polish,artificial nails,All of these have been proven to retain bacteria,and the worst bacteria they retain is the E.coli when you go to the bathroom,and theres even a saying never eat from a lady with long finger nails they even apply this in restaurants.so in the clinics whether the doctor checked up on you or not,you should always stick to the rules because safety is more important than fashion and guys are included in this as well. The same goes for jewelry,the problem with jewelry is that not only they retain bacteria,they can tear the gloves as well when youre wearing them. Personal Protective Equipment 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

 Wear a surgical mask and either eye protection with solid side shields or a 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 Wear gowns, lab coats, or uniforms that cover skin and personal clothing likely to become soiled with blood, saliva, or infectious material Change if visibly soiled Remove all barriers before leaving the work area Minimize the risk of health care personnel acquiring infections from patients Prevent microbial flora from being transmitted from health care personnel to patients Reduce contamination of the hands of health care personnel by microbial flora that can be transmitted from one patient to another Are not a substitute for handwashing! Wear gloves when contact with blood, saliva, and mucous membranes is possible Remove gloves after patient care Wear a new pair of gloves for each patient Remove gloves that are torn, cut or punctured Do not wash, disinfect or sterilize gloves for reuse * They have done a study on doctors and took samples from their bodies all around and found out that the place where the most bacteria are found,were their tie (for males),for females its the same area (underneath the neck).because when you wear a labcaot, that is the area exposed,unless you wear a labcoat with a neck strap which is safer and this is what you should wear in you clinic as a dentist to keep this area clear from patients materials. Latex Hypersensitivity and Contact Dermatitis Latex Allergy Type I hypersensitivity to natural rubber latex proteins Reactions may include nose, eye, and skin reactions

 More serious reactions may include respiratory distressrarely shock or death

Contact Dermatitis Irritant contact dermatitis -Not an allergy -Dry, itchy, irritated areas Allergic contact dermatitis -Type IV delayed hypersensitivity -May result from allergy to chemicals used in glove manufacturing Solutions regarding hypersensitivity are: Educate DHCP about reactions associated with frequent hand hygiene and glove use Get a medical diagnosis Screen patients for latex allergy Ensure a latex-safe environment Have latex-free kits available (dental and emergency) *Sterilization and Disinfection Sterilization is completely removing all types of bacteria While disinfection only part of them (the most hazardous) How do we classify instruments?? Critical Instruments (anything that touches blood) Penetrate mucous membranes or contact bone, the bloodstream, or other normally sterile tissues (of the mouth) Heat sterilize between uses or use sterile single-use, disposable devices Examples include surgical instruments, scalpel blades, periodontal scalers, and surgical dental burs Semi-critical Instruments (touch the saliva and mucosa)

 Contact mucous membranes but do not penetrate soft tissue Heat sterilize or high-level disinfect Examples: Dental mouth mirrors, amalgam condensers, and dental handpieces Noncritical Instruments and Devices (used only from the outside) Contact intact skin Clean and disinfect using a low to intermediate level disinfectant Examples: X-ray heads, facebows, pulse oximeter, blood pressure cuff As for the areas,you have the area youre working in,they have their own classification (environmental surfaces),but then you have the area where you take the instruments and clean them,it has another classification (instrument preparation processing area) for sterilization and this is divided into dirty,clean and semi-clean area.the area after sterilization is called a clean area,the area which the patient comes from is called a dirty area. So the instrument processing area is divided into work areas Receiving, cleaning, and decontamination Preparation and packaging Sterilization Storage We have different types of heat sterilization,but the most reliable is called Autoclave ,youll be seeing it in the clinics,but there are instruments we dont put in the autoclave though because heat will affect them so we sink them in disinfectants. Now I need to make sure that my devices are sterilized by something called indicators, there are : Mechanical indicators Measure time, temperature, pressure Chemical indicators Change in color (of a tape placed inside) when physical parameter is reached Biological indicators(spore tests) most accurate

 Use biological spores (inactive but still infectious solid state of a bacteria with minimum metabolic activity,but become active when reaching a good host,for example TB) to assess the sterilization process directly,if the autoclave didnt eliminate all spores then it needs to be changed. Now the area around the patient,it gets contaminated with aerosols as youve seen before in the video,so we have 2 types of Environmental Surfaces : Clinical contact surfaces (for example,door handle) High potential for direct contamination from spray or spatter or by contact with DHCPs gloved hand Housekeeping surfaces (for example,the walls,the sink) Do not come into contact with patients or devices Limited risk of disease transmission

Medical waste should be thrown away directly,because it has infectious material inside,also sharp materials should be placed in sharps containers,these containers will not be ruptured and the materials wont go outside it. Regulated Medical Waste Management Properly labeled containment to prevent injuries and leakage Medical wastes are treated in accordance with state and local EPA regulations (for example if youre working at JUST university ,JUST has a medical waste area where they throw materials,youll see it when you go to the clinics,youll notice the trash area,its devided into differently colored containers,each container has a different type of material,like materials with blood should have a special container,these go to specialized areas of sanitization.) Processes for regulated waste include autoclaving and incineration

Dental Unit Waterlines, Biofilm, and Water Quality Waterlines are filled with bacteria,in the tubes that you use in the clinic,so all of these should be also cleaned,you flush them and you can use the following technology,either you get water not form the main supply,you get a tank of water that you fill instead,or you could add to it chemicals,or special filters to the water to make sure baterica doesnt pass through or even the combination of these! Or you sometimes could use sterile water delivery especially if youre going to do surgery,and ofcourse you dont want contamination in your surgery. You make sure you monitor everything,(in slide 81) this is sterile water taken by the syringe,and the nurse keeps pushing the water through the syringe on the place youre working on to keep it sterile.

These are special considerations on how to deal with : * 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 manufacturers instructions for cleaning, lubrication, and sterilization Do not use liquid germicides or ethylene oxide

* Components of Devices Permanently Attached to Air and Waterlines Do not enter patients mouth but may become contaminated Use barriers and change between uses Clean and intermediate-level disinfect the surface of devices if visibly contaminated * Saliva Ejectors

 Previously suctioned fluids might be retracted into the patients mouth when a seal is created Do not advise patients to close their lips tightly around the tip of the saliva ejector * Dental Radiology Wear gloves and other appropriate personal protective equipment as necessary Heat sterilize heat-tolerant radiographic accessories Transport and handle exposed radiographs so that they will not become contaminated Avoid contamination of developing equipment

* Parenteral Medications Definition: Medications that are injected into the body Cases of disease transmission have been reported Handle safely to prevent transmission of infections

* Precautions for Parenteral Medications IV tubings, bags, connections, needles, and syringes are single-use, disposable Single dose vials Do not administer to multiple patients even if the needle on the syringe is changed Do not combine leftover contents for later use * Single-Use (Disposable) Devices Intended for use on one patient during a single procedure Usually not heat-tolerant Cannot be reliably cleaned Examples: Syringe needles, prophylaxis cups, and plastic orthodontic brackets * Preprocedural Mouth Rinses

 Antimicrobial mouth rinses prior to a dental procedure Reduce number of microorganisms in aerosols/spatter Decrease the number of microorganisms introduced into the bloodstream Unresolved issueno evidence that infections are prevented

* Oral Surgical Procedures Present a risk for microorganisms to enter the body Involve the incision, excision, or reflection of tissue that exposes normally sterile areas of the oral cavity Examples include biopsy, periodontal surgery, implant surgery, apical surgery, and surgical extractions of teeth.

* A little piece of information*: Creutzfeldt-Jakob Disease (CJD) ,this is not a virus,its even smaller than a virus,its called a prion,it causes Bovine spongiform encephalopathy (BSE),or as commonly know as cow madness disease,this is a very big problem in Britain,to the point that if they do a surgery to a patient who has this disease they will throw everything away,even the table on which they do the surgery,they change it,also the sheets,they change EVERYTHING,because they know that this patient is highly infected. Its a common disease in the western countries because there they feed the cows on other types of meat.

The end
I tried to include some of the information in the slides,I apologize for any mistakes present in this lecture and would be really thankful if you could let me know what they are study well! Done by: Ruby Daoud <3