1. INFECTION CONTROL IN DENTAL PRACTICE
Dr Arun George MDS
Maxillofacial Surgeon, India
Mar Baselios Dental College

2. STERILIZATION
INSTRUMENT MANAGEMENT

4. Why Is Infection Control Important in Dentistry?
Both patients and dental health care personnel (DHCP) can be exposed to pathogens
Contact with blood, oral and respiratory secretions, and contaminated equipment occurs
Proper procedures can prevent transmission of infections among patients and DHCP
During the provision of dental treatment, both patients and dental health care personnel (DHCP) can be exposed to pathogens through contact with blood, oral and respiratory secretions, and contaminated equipment.
Following recommended infection control procedures can prevent transmission of infectious organisms among patients and dental health care personnel.

5. Dental patients and dental health care workers may be exposed to a variety of microorganisms such as bacteria, viruses, and fungi during dental treatment
Among these, the diseases of foremost concern are infections caused by
Human immunodeficiency virus (HIV)
Hepatitis viruses B, C, and D
Mycobacterium tuberculosis

6. Infections may be transmitted in the dental operatory through the following routes
Direct contact with blood, oral fluids, or other secretions
Indirect contact with contaminated instruments, operatory equipment, or environmental surfaces
Contact with airborne contaminants present in either droplet spatter or aerosols of oral and respiratory fluids

7. Modes of Transmission Direct contact with blood or body fluids
Indirect contact with a contaminated instrument or surface
Contact of mucosa of the eyes, nose, or mouth with droplets or spatter
Inhalation of airborne microorganisms
Dental patients and DHCP may be exposed to a variety of disease-causing microorganisms that are present in the mouth and respiratory tract. These organisms may be transmitted in dental settings through several routes, including:
Intact or non-intact skin in direct contact with blood, oral fluids, or other potentially infectious patient materials.
Indirect contact with a contaminated object (e.g., instruments, operatory equipment, or environmental surfaces).
Contact of mucous membranes of the eyes, nose, or mouth with droplets (e.g., spatter) containing microorganisms generated (e.g., coughing, sneezing, talking) from an infected person and propelled a short distance.
Inhalation of airborne microorganisms that can remain suspended in the air for long periods of time.

8. Route of transmission Inoculation:
Direct contact of previously damaged skin or mucous membrane with a lesion, organism, or debris while performing intra-oral procedures.
Accidental self injury with a contaminated needle, or sharp instruments

9. Inhalation
Inhalation of microorganisms aerosolized from a patient’s blood or saliva occurs when using high speed or ultrasonic instruments

10. Universal precautions
Universal precautions are a set of precautions designed to prevent transmission of HIV, HBV, and other blood borne pathogens when providing first aid or health care
Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV, and other blood borne pathogens

11. Needles, scalpels, and other sharp instruments or devices
Universal precautions - involve the use of protective barriers such as gloves, gowns, aprons, masks, or protective eye wear
Needles, scalpels, and other sharp instruments or devices
which can reduce the exposure of skin and mucous membrane to potentially infective materialsIn addition, it is recommended that all health care workers take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices

12. Hand Hygiene & Personal Hygiene
Hands are the most common mode of pathogen transmission
Reduce spread of antimicrobial resistance
Prevent health care-associated infections
Next we turn to the subject of Hand Hygiene. So, is hand hygiene the single most important factor in preventing the spread of pathogens in health care settings?
First, hands are the most common mode of pathogen transmission.
Hand washing can reduce the spread of antibiotic resistance in health care settings and the likelihood of health care-associated infections.
[Additional comments: CDC estimates that each year nearly 2 million patients in the United States acquire infections in hospitals, and about 90,000 of these patients die as a result.]

13. Personal Hygiene Visibly dirty
After touching contaminated objects with bare hands
Before and after patient treatment (before glove placement and after glove removal)
CDC recommends that hands be cleaned:
When they are visibly dirty.
After touching contaminated objects with bare hands.
Before and after patient treatment, that is, before glove placement and immediately after glove removal.
Photo credit: Centers for Disease Control and Prevention, Atlanta, GA.

14. Personal Hygiene
No finger nails and rings
No watch
Put up u r hair

15. Personal hygiene
All dental staff who come into direct contact with patients should practice meticulous personal hygiene
Fingernails must be kept short and jewellery on the hands and watches should be removed since they tend to trap organisms and may tear the gloves
Hair should be put up tightly
It is a good practice to wash the hands before and after treatment with a non-irritant antimicrobial hand wash solution
Do not touch one’s own eyes, nose, mouth, hair or other items like patient records, computer key boards, telephone receiver, drawer handles, pen etc with contaminated hands
Never leave the clinic wearing aprons or overcoats

16. Hand Hygiene Definitions
Handwashing
Washing hands with plain soap and water
Antiseptic handwash
Washing hands with water and soap or other detergents containing an antiseptic agent
Alcohol-based handrub
Rubbing hands with an alcohol-containing preparation
Surgical antisepsis
Handwashing with an antiseptic soap or an alcohol-based handrub before operations by surgical personnel
Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis.
Handwashing refers to washing hands with plain soap and water.
Antiseptic handwash refers to washing hands with water and soap or other detergents containing an antiseptic agent, such as triclosan or chlorhexidine.
Using a waterless agent containing 60%–95% ethanol or isopropanol alcohol-containing preparation is referred to as an alcohol handrub. These agents are a new addition to the dental guidelines and have become more frequently used in the United States to improve compliance with handwashing in hospitals. In dental practices, however, sinks are readily available and the need for alcohol preparations is not as great.
Surgical antisepsis refers to an antiseptic handwash or alcohol-based handrub* performed preoperatively by surgical personnel to eliminate microorganisms on hands. Antiseptic preparations for surgical hand hygiene should have persistent (long-lasting) antimicrobial activity.
* If using an alcohol-based handrub the hands should first be washed with soap and water.

17. Barrier techniques
The proper use of barrier techniques as part of universal precautions is extremely important
The wearing of gloves, masks, protective eyewear, and clinic attire by all personnel who have direct contact with the patient is required for all treatment, regardless of their nature

18. Gloves Surgical gloves Examination gloves
Utility gloves: heavy rubber gloves used for cleaning instruments and environmental surfaces
Gloves can be autoclaved and reused; but they must be discarded if they are cracked, discolored or have punctures, tears or other evidences of deterioration

19. Aerosols
Aerosol is defined as small droplets, usually 50 μm or less in diameter, which can remain suspended in air for some time.
The smaller particles of an aerosol have the potential to penetrate and lodge in the smaller passages of the lungs and are thought to carry the greatest potential for transmitting infections
Diseases such as tuberculosis, influenza, and SARS (Severe Acute Respiratory Syndrome) are known to be spread by droplets or aerosols

20. Dental handpieces, airotors, air/water syringes, and ultrasonic scalers produce large amounts of aerosols.
The risk of infection from aerosols can be minimized by
Use of protective barriers
Pre-procedural rinsing with 0.2% chlorhexidine; reduces the bacterial count in the aerosols
Proper patient positioning
Use of saliva ejectors and high volume suctions

21. Saliva Ejectors
Previously suctioned fluids might be retracted into the patient’s mouth when a seal is created
Do not advise patients to close their lips tightly around the tip of the saliva ejector
Backflow, meaning reverse flow, can occur when there is more negative pressure in the patient’s mouth than in the evacuator tubing, for example, when the patient uses the saliva ejector as a straw. When this happens, material from the mouth of a previous patient might remain in the vacuum line of the saliva ejector and be aspirated into the mouth of the next patient being treated.
Although there have been no reports of any adverse health issues, patients should not be instructed to close their lips tightly around the saliva ejector tip during use.
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

22. HIGH VOLUME EVACUATION
(SUCTION)
SALIVA EJECTOR

23. Biofilms
Adhesion of bacteria and other microorganisms to solid surfaces in aqueous environments can result in the formation of a slime-like material called biofilm
Biofilm protects the bacteria from disinfectants and can trap other potentially infective microorganisms

24. Biofilms can form within dental water lines by two ways
Bacteria may be pulled into the water lines during treatment from the patient’s mouth which may later transmit to other patients
Bacteria present in the main water supply can concentrate in the dental unit water line especially in warm and stagnant conditions

25. Biofilm formation can be minimized by
Independent water reservoirs for the dental unit
Using sterile water
Drain and flush water lines for several minutes before beginning clinic each day
After each patient, run high-speed handpieces and scalers for a minimum of seconds to discharge contaminated water and air that may have entered the water line

26. Dental Unit Waterlines and Biofilm
Microbial biofilms form in small bore tubing of dental units
Biofilms serve as a microbial reservoir
Primary source of microorganisms is municipal water supply
Studies have shown that colonies of microorganisms, or biofilms, can form on the inside of the small-bore plastic tubing that transports water within the dental unit to handpieces and air-water syringes. Once formed, a biofilm serves as a reservoir that may dramatically increase the number of free-floating microorganisms in water used for dental treatment.
Most organisms isolated from dental water systems originate from the public water supply and do not pose a high risk of disease for healthy persons. Although a few pathogenic organisms, such as Legionella spp. and Pseudomonas sp., have been found, adverse public health threats have not been documented.
Photo credit, top: CDC Image library. This Scanning Electron Micrograph depicts an E. coli (ATCC 11775) biofilm grown on PC (polycarbonate) coupons using a CDC biofilm reactor. Photo credit, bottom: Illustration from the Center for Biofilm Engineering, Bozeman MT.

27. Flushing the scalers and handpieces (bleeding) for 30 seconds between each patient can discharge the contaminated water that have entered the water line

28. Handling of sharp instruments
Care must be taken while handling needles and other sharp instruments during and after procedures, while cleaning used instruments, and during disposal of used needles.
Forceps must be used to handle sharp instruments
Disposable needles, scalpel blades and other sharp items should be discarded into puncture-resistant containers that are easily accessible for disposal

29. When recapping needles, both hands should never be used; instead, a one-handed “scoop technique” or another instrument should be used
“scoop technique”
Wrong method

30. Handling sterile instruments
Never touch sterile instruments or other materials like cotton with contaminated gloved hand or used instruments
Sterilized materials and instruments should be handled with a sterilized cheatel forceps, which should be stored with the tip immersed in a disinfectant solution

31. Chittle Forceps

32. Anaesthetic Solution

33. Local Anaesthetic
If repeated injections are required, the used syringe should be discarded and a new one taken

34. Special Considerations
Dental handpieces and other devices attached to air and waterlines
Dental radiology
Single-use (disposable) Devices
Preprocedural mouth rinses
Oral surgical procedures
Handling biopsy specimens
Handling extracted teeth
Laser/electrosurgery plumes or surgical smoke
Dental laboratory
Mycobacterium tuberculosis
Creutzfeldt-Jacob Disease (CJD) and other prion-related diseases

35. Sterilization
Process by which all forms of microorganisms including viruses, bacteria, fungi, and spores over articles or surfaces are destroyed
Articles or objects free of living organisms are termed sterile

36. Methods of sterilization
Moist heat (autoclaving)
Dry heat (hot-air oven)
Chemicals (chemiclaving)

37. Most preferred method of sterilization
Steam Under pressure

38. Recommended sterilization cycles for autoclaving
Temperature
Time
Pressure
Unwrapped
instruments
1340C
3 min
30 psi
Wrapped
1210C
15-20 min
15 psi

39. Packaging and sealing of instruments
Instruments should be carefully packaged in functional sets before sterilization.
This packaging protects the instruments after sterilization and before use at chair side
A variety of packaging materials are available
Self-sealing, paper-plastic, peel pouches are the most convenient

40. Some packaging materials have indicators which change color when sterilization is completed

41. Boiling
Immersion of instruments in boiling water does not achieve sterilization as many of the bacterial spores can withstand boiling
Cross infection from contaminated water containing bacterial spores not killed by boiling is also a possibility

42. Classification of Instruments to be Sterilized
Dental instruments are classified into three categories depending on their risk of transmitting infection and the need to sterilize them between use
critical
Semi-critical
Non-critical

43. Critical
Surgical and other instruments used to penetrate soft tissue or bone
Should be sterilized after each use
Examples are
Forceps, periosteal elevators, cross bars
Scalpels, scissors, suture needles
Bone chisels
Surgical burs
Scaling instruments
Endodontic instruments

44. Semi-critical
Instruments that do not penetrate soft tissue or bone but contact oral tissues
These instruments should also be sterilized after each use
Examples are
Mouth mirrors
Burs
Handpieces
Tweezers
Restorative instruments
Impression trays

45. Non-critical
Those items, which do not come into contact with body fluids
Have a relatively low risk of transmitting infection
Examples are
Medication bottles
Light cure tips
Glass slab and cement spatula
Instrument trays
Orthodontic pliers
Dapen dish

46. Surface asepsis
Use surface barriers to protect clinical contact surfaces, particularly those that are difficult to clean (e.g., switches on dental chairs)
Change surface barriers between patients

47. Disinfection of Dental Equipments
Clinical contact surfaces and dental equipments that are not covered should be cleaned and disinfected with a hospital level disinfectant (activity against HIV, HBV, and Mycobacterium tuberculosis) after each patient.
Sodium hypochlorite (household bleach) is an effective and economical surface disinfectant

48. DISINFECTANTS

49. Antiseptics Biguanides: Chlorhexidine Low toxicity
Used on skin and mucous membranes

50. Clinical Contact Surfaces
This slide shows some examples of clinical contact surfaces, including a light handle, countertop, bracket tray, dental chair, and door handle (shown by arrows).
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

51. Housekeeping Surfaces
Examples of housekeeping surfaces are walls, sinks, and floors (shown by arrows).
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

52. Spray-wipe-spray technique
Spray the disinfectant solution on the surface
Using a gauze piece, wipe the surfaces in overlapping strokes
Spray again
Allow the disinfectant to dry on the surface for about 10 minutes

55. Autoclaving

56. U V Chamber
Ultraviolet germicidal irradiation (UVGI) is a disinfection method that uses short-wavelength ultraviolet (UV-C) light to kill or inactivate microorganisms by destroying nucleic acids and disrupting their DNA, leaving them unable to perform vital cellularfunctions.[1] UVGI is used in a variety of applications, such as food, air, and water purification.
UV-C light is weak at the Earth's surface as the ozone layer of the atmosphere blocks it.[2] UVGI devices can produce strong enough UV-C light in circulating air or water systems to make them inhospitable environments to microorganisms such as bacteria, viruses,molds and other pathogens. UVGI can be coupled with a filtration system to sanitize air and water.
The application of UVGI to disinfection has been an accepted practice since the mid-20th century. It has been used primarily inmedical sanitation and sterile work facilities. Increasingly it has been employed to sterilize drinking and wastewater, as the holding facilities are enclosed and can be circulated to ensure a higher exposure to the UV. In recent years UVGI has found renewed application in air purifiers.

57. Instrument Storage

59. Autoclaved Towel

60. Gloves

62. Hand Disinfectants

63. Alcohol
Alcoho

64. 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 manufacturer’s instructions for cleaning, lubrication, and sterilization
Do not use liquid germicides or ethylene oxide
Any removable device that is attached to the air or waterlines should be heat sterilized to ensure that internal components have been sterilized.
It is very important to follow the manufacturer’s instructions for cleaning and lubrication. These protocols can ensure the effectiveness of the process and contribute to the life of the device.
Surface disinfection or liquid chemical germicide immersion are not acceptable. In addition, the use of ethylene oxide is not recommended because it cannot reliably penetrate the internal components.

65. Handpiece Disinfection & Oiling
Handpiece piece cleaning mechanism……

66. Hand pieces should be dried and kept upsaid down after proper oiling and disinfecting and can be taken up for autoclaving for any surgical uses.

67. Air Compressor
Air filters to be attachd to all aircompressors…… if needed periodically remove and clean the filters…….

68. Waste Management
Dental clinic waste should be handled properly and should be transported for proper waste disposal……most of the clinics in kerala will have image will have image waste disposal system……

69. Sharp Instruments

70. Dental Chair Care
Chair needs to be raised for proper drainage and biofilim formation, Disinfectant solution can be used to inside the suction and drainage channels periodically.

71. Apron

73. Infection Control Program Goals
Provide a safe working environment
Reduce health care-associated infections
Reduce occupational exposures
The goal of an infection control program is to provide a safe working environment for DHCP and their patients.
We can accomplish this by adopting measures that will reduce health care-associated infections among patients and occupational exposures among DHCP.