Infection control

Continuous dental education Jabatan Pergigian 96 Hospital Angkatan Tentera

Introduction
In dental practice, there is a significant risk of

cross infection between patients and oral healthcare workers (OHCW).

Cross infection: Infection transmitted from individuals infected with diff pathogens to healthy individuals.

Infection control protocol should be carried out in

any situation possible.

Standard precaution concept

Previously known as

universal precaution

All blood and body fluids, secretions, and

excretion (exc sweat) regardless of whether they are contaminated with blood are infectious when it comes into contact with non-contact skin and/or mucous membrane.

Responsibilities of OHCW
Personal protective equipment (PPE)
gloves, masks, protective eyewear, face shields and protective clothing

Hep B vaccination

Hand hygiene

Medical Hx of patient

Cleaning, disinfection & sterilisation of patient care items

Instrument classification

Instrument processing area

Instrument cleaning

Instrument packaging

Sterilisation

Storage

Disinfection
A process, which reduces vegetative microorganism but NOT bacterial spores

Sterilisation
Use of a physical or chemical procedure to destroys ALL microorganisms including bacterial spores

Instrument classification
a)

Critical instruments

Penetrate soft tissue/bone, blood E.g. forcep, scalers, burs, bone rongeur Need to be sterilised

b)

Semi-critical instruments

Do not penetrate soft tissue/bone Contacts oral tissue or x-intact skin E.g. mouth mirror, handpieces, amalgam condenser Sterilise / high level disinfectant

c)

Non-critical instruments
Contact intact skin E.g. xray cone, facebow Low/ intermediate level disinfectant

Processing area
One way; dirty clean sterile area Divided into 3 sections:
Decontamination area receiving, cleaning

and decontamination Packaging area sorting and packaging Sterilizing area sterilization and storage

Decontamination area

Packaging area

Sterilizing area

Instrument cleaning
3 Reasons for cleaning:
Reduce bacterial counts Reduce corrosion, rusting, pitting Remove visible debris

 PPE

Wipe blood in surgery

Soak detergent/enzymatic cleaner, disinfectant Ultrasonic cleaners - Cavitation bubbles induced

by the agitation act on contaminants Rinse with water dry pack for sterilization

Types of disinfectants
There are several types, most commonly used are:
Alcohol Highly concentrated amounts of alcohol (70% and higher) can kill bacteria by damaging the plasma membrane and denaturing proteins within the cell. Ineffective against spores, viruses Aldehyde e.g. formaldehyde , glutaraldehyde wide microbiocidal activity and are sporocidal and fungicidal. It acts by protein denaturation and reacting with the amine group in the cells, thus acting as a cytotoxic agent Sterilization time is 10 12 hours. Disinfection time is 10 minutes. Oxidizing agents e.g. sodium hypochlorite, iodine oxidizing the cell membrane of microorganisms, which results in a loss of structure and leads to cell lysis and death

Materials for disinfection

Gigasept ID 212 DURR instruments disinfectant TriGene Mikrozid Alprosol

Al projet
Orotol plus suction system Rotasept Desmanol Manugel Antibacterial skin cleanser

Gigasept
Disinfect instruments:
Static bath Suitable for ultrasonic

Directions:
Immerse, rinse with water after contact time

elapse

5 % 5 min,

2 % 15 min, 0.75 % 30 min

20ml gigasept + 980ml water

Ultrasonic; 2% - 5mins Can be used for 7days or

until colour change

ID 212 DURR instruments disinfectant

disinfecting and cleaning general and surgical

instruments as well as rotating instruments Ready to use 2% solution Better smell than Gigasept Direction:
Static bath - 5mins Ultrasonic 2mins 7 days standing time

TriGene
Broad spectrum surface disinfectant cleanser

Better than sodium hypochlorite disinfectant

Directions:
Same as Gigasept Use the 1:50 ratio, proven to be effective at this

conc.

Mikrozid
alcohol-based

Mikrozid liq and/or wipes

disinfect high risk surfaces Fast acting Directions:
Wipe/spray surfaces and leave to dry ~ 5mins

Alprosol
Cleaning of impression trays and instruments MOA dissolves cements, alginates, ZOE and

adhesive varnishes Directions

Prepare a 3-5% solution Slightly clean instruments and impression trays Leave in solution for a few hours Remove softened residues under running water and brush Standing time 2-3days

Can be used with u/sonic devices.

Alprojet-W
maintenance and disinfection of all dental

aspiration and separation systems

Directions:
weekly cleaning 5% mixture ( 100ml solution +1900ml warm

water) 2L Use end of the day Rinse with water before starting work in the morning

Orotol plus suction system

Disinfection of suction systems

Directions:
Once daily disinfecting and cleaning End of the day Prepare 2% solution Fill 20 ml OrotolPLUS up to 1 litre with cold

water and draw through suction system, using the OroCup or the orotol Care System 60mins

Rotasept
disinfectant and cleaner for burs, cutters,

grinders, finishers, brushes and polishers Directions:

Static bath 30mins Ultrasonic 15mins Change solution daily

Desmanol
rapid acting alcohol based handrub

Suitable for both hygienic and surgical hand

disinfection Do not wash off, suitable for field Contains emollients for skin care protection Directions:
Hygiene: 3ml, 30sec Surgical: 2x5ml, 3mins

Manugel
Hydroalcoholic antiseptic gel

Do not wash off, suitable for field

Directions:
Hygiene: 3ml, 30sec Surgical: 2x5ml, 3mins

Antibacterial skin cleanser

Liq. soap with antibacterial properties for

handwashing

Disinfection of impression materials

Common alginates and polyether

Clean under running water to remove debris, blood and saliva. 2. Spray 0.05% NaOHCl. 3. Wrap impression in gauze & place in plastic 10mins. 4. Rinse under running water before pouring stone/POP.
1.

Maintenance of handpiece
Autoclavable: e.g. Bien Air Before/between patients: 1. Run handpiece for 20-30 sec 2. Wash/scrub with detergent and water 3. Leave to dry
Autoclavable After patients: 1. Lubricate with ASSISTINA 2. Place in pouch 3. Sterilize in autoclave.

Maintenance of handpiece
Non autoclavable: e.g. A-dec

Non autoclavable

Before/between patients: 1. Run handpiece for 20-30 sec 2. Wash/scrub with detergent and water 3. Wipe with paper towel 4. Wipe with disinfectant 5. Wrap an absorbent material containing 70% and cover with plastic cover for 10mins

After patients: 1. Lubricate with ASSISTINA

ASSISTINA
how it works??
uses a special cleaning liquid to flush internal

air/water coolant lines, removing debris and preventing scale buildup provides consistent lubrication with automatic oil dispensing system spins gears and turbines during purge cycle to help expel debris and excess oil
Directions:

Press button for 2 sec Only 35 sec per cycle

Kleen Machine
For intensive internal cleaning and lubrication of

dental handpieces 3 to 4 instruments treated in 1 cycle 2 fully automatic maintenance programmes: standard and intensive

Syringe Destroyer BD-300A

low voltage electric shock can melt the needle

instantly approximately 3 sec working time Prevents needlestick injuries during disposal.

Instruction: 1. Clean all liquid out of the syringe before destroying. 2. Insert the needle into the melting port first then press down gently until it reaches the metal plate 3. While the safeguard indicator lights up, it shows that the machine is in a protected state because of high temperature. 4. Can work normally after 3-5mins.

Exposure incidents
Exposure of of OHCW to blood and body

fluids of a patient Risks of acquiring HIV, HBV, and HCV Consider Post-Exposure Prophylaxis (PEP)
prophylactic treatment started

immediately after exposure to a pathogen (such as a disease-causing virus), in order to prevent infection by the pathogen and the development of disease.

Types of exposure: Percutaneous injury Contact of mucous membrane with blood Contact of non-intact skin with blood Contact of intact skin with blood

Prevention Strategies
Knowledge; education, training & standard

operating procedures to all OHCW in the organization

Work practice controls:

Before procedure During procedure Cleaning up

Disposal of sharps

Management of exposure incident

1.

Treat the exposure site

Decontaminate
wound and skin sites wash with soap and water Mucous memb flush with water Eyes rinse gently with water/normal saline with eyes opened

No evidence that use of aniseptic or squeezing the wound reduces risk of transmission of pathogens

2. 3.

Inform employer/ supervisor and document the incident Refer to Hospital/health clinic according to the local guidelines

 Collection of information:

Date,time of exposure Details of procedure performed Details of exposure

Evaluation of:

Patient infection status?? If not known, informed

consent for testing is taken after counseling. If source is seronegative and no symptoms, no further testing is done Exposed OHCW referred to physician for evaluation & baseline testing within hours

Packaging
Cleaned instruments arranged in a sets or

individual items Dry before packing Critical & semi-critical instruments must be packaged / placed into container for sterilization to:
Allow penetration of steam Maintain sterility of items after sterilization Examples: plastic/paper peel pouches and

sterilization wraps

External/internal chemical indicator can be used

Sterilization
All semi-critical and critical instruments must be

autoclaved if possible

Types of autoclave:

Vacuum (Type B or S) Downward/gravitational displacement (Type N)

Sterilization time:

134 C for 3 minutes 121 C for 15 minutes

Drying cycle adds ~ 17mins

Type B (vacuum)

Sterilizes any kind of object e.g. solid instruments, porous and hollow objects, both single and double packaged and un-packaged instruments Sterilizes un-packaged solid instruments plus one or more of the other types of instruments indicated for Type B e.g. single wrapped and hollow instruments (specified by the manufacturer) Sterilizes only un-packaged solid instruments

Type S (vacuum)

Type N ( nonvacuum / downward displacement)

Vacuum autoclaves
1. The Pre Vacuum uses a powerful vacuum pump to ensure the removal of all the air from within the chamber prior to sterilization.

2.

In the absence of air, steam is able to penetrate to all instrument surface, including inside the narrow lumens of hollow instruments such as complete dental handpieces and scopes.

3.

The use of vacuum autoclave is also imperative if instrument pouches or bags are to be used.

4.

On completion of the selected sterilizing cycle, the Pre Vacuum automatic, pulse, postvacuum drying phase, ensures instruments are perfectly dry.

5.

The post vacuum drying of the instruments helps keep valuable instruments in good condition and prolong their life.

The Non - Vacuum Autoclaves

1. As pressurized steam enters the chamber, air is forced out, allowing the steam to come into contact with all instrument surfaces, destroying harmful bacteria and spores.

2. When an extremely fast turnaround of instruments is required, selecting the standard non-vacuum cycle, without drying, can offer a total cycle of 13 minutes.

3. Non-vacuum autoclaves are particularly suitable for applications where predominantly solid instruments are used and a fast turnaround is crucial.

Eschmann SES 2000 Autoclave

A non-vacuum autoclave, Type N,
only suitable for processing solid unwrapped

instruments. They are not suitable for sterilizing instruments that have lumens (hollow cavities), items wrapped or enclosed in pouches, and porous (absorbent or linen)loads.

Pouches must be only sterilized usning the

134 C with drying

Vacuum Autoclave Melag Euroclav 23VS

Type S

Programs: Universal, Quick, Gentle, Prion

Indication:
sterilisation of single wrapped instruments, solid

instruments, unwrapped instruments, multi wrapped instruments and porous loads as represented by the draft paper.

Zenith autoclave
type 'B' autoclave

Indication:
which has been designed specifically for the rapid

sterilization of complex, hollow instruments, including dental handpieces.

LISA 500
Type B autoclave - can be used with wrapped or

unwrapped, solid, hollow, porous or mixed loads.

Sterilisation monitoring
The CDC Guidelines advise healthcare providers

to use a quality assurance monitoring program that includes three components:

Physical - observe and record mechanical gauges Chemical - color change ink on every package

and in every load

Biological spore testing

Temperature
International Units of Pressure

Verify sterilization process psi mb bar has taken place but 1.03 that not 121 Pressure 15 103 1030 actual sterilization has 126 138 20 1380 1.38 132 186 27 1860 occurred !!! 1.86
Temp C kPa 134 203 30 2030 2.03

Holding time (minutes) 15 10 4 3

Time

Class 1 indicators
External indicators distinguish btw packages (pre-, post-processed) e.g. autoclave tape or markings on pouches

Class 2 indicators
Indicators are used for specific tests e.g Dynamic Air Removal test (Bowie Dick test) Uses chemical ind. in a test pack to see if air removal and steam penetration is adequate

Class 3 indicators

Single parameter ind. react to only one parameter e.g. temperature tube

Do not prove sterilization has been achieved Class 4 indicators NOT a replacement for Multiparameter ind. react to more than one parameter usu. @ biological monitoring specific temperature
Class 5 indicators
Integrating indicator react to all parameters over a specific range of temperatures

Class 6 indicators
Emulating ind. react to all parameters based on a specific sterilization cycle

Vials / strips containing harmless bact. spores

Culture

+ve culture = -ve sterilization

Sterilization cycle

Should be performed at least once a week

Storage
Stored packaged in enclosed area Inspect - Intact barrier & dry Package must be dated

Types of storage: Shelf-life practice usually 1 month. Event-related practice instrument should remain sterile unless an event causes it to become contaminated. Practically not stored more than 6 months.
If compromised, re-clean, packaged & sterilize again

Items in the OT
TriGene

Cidex OPA
Eschmann SES 2000 Autoclave

TriGene
Step 1 Rinse under running water Disinfect 10mins with Trigene (1:20) Manual cleaning brush Rinse Dry pack autoclave Step 2 Rinse under running water Put in u/sonic cleaner (Soniclean) Drypack Autoclave

Cidex OPA
ortho-Phthalaldehyde Solution high level disinfectant for reprocessing heat

sensitive reusable semi-critical medical devices, for which sterilization is not feasible Directions:
Blood, other body fluids, and lubricants must be

thoroughly cleaned Rinse and rough dry Immerse instruments for 12mins After removal, immerse in large volume of sterile water for 1min. Discard water and repeat rinse 2 additional times

14 days standing time