INFECTION
CONTROL
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The
premise of infection control is that precautions minimize the risk of exposure
to pathogens, thereby protecting health care professionals from occupationally
acquired infections. Do you need to
practice infection control? If you are
exposed to blood, saliva, gingival fluid, or mucous membranes, either directly
or indirectly during your workday activities, then you need to protect yourself
by following infection control guidelines.
Fluids and tissues are vectors that transmit infectious agents. Nearly all patient care procedures expose
dental professionals to body fluids and tissues.
The
most efficient way to prevent transmission of disease during patient care is to
integrate infection control methods with treatment procedures. Infection control should be the environment
in which patient care occurs.
GOALS
OF INFECTION CONTROL
The
purpose of infection control for dentistry is to prevent transmission of
disease during dental treatment by using a concept called standard/universal precautions.
Using standard/universal precautions for all patients prevents cross‑infection
among dental professionals and patients.
OBJECTIVES
·
FIRST
PROTECT YOURSELF from occupational acquired infections; REDUCE the numbers of
cross‑infecting pathogens.
·
BREAK
the chain of cross‑infection.
·
APPLY
standard/universal precautions;
TREAT every case as if the patient had a positive diagnosis for hepatitis B,
HIV infection or AIDS, tuberculosis, or other serious infectious disease.
·
PROTECT
patients from cross‑infection. PROTECT
incomes of dental professionals.
·
PROTECT
dental professionals from liability for negligence and/or noncompliance with
federal, state, and local regulations.
GOAL
OF THIS DOCUMENT
The
objectives of the Infection Control Program are achieved by strictly applying
common sense principles related to seven components. These will be described
thoroughly, as they are applied in the Dental Hygiene Program of the
COMPONENTS
OF INFECTION CONTROL
1. Medical screening
2. Personal protection (management of
exposures)
3. Instrument sterilization
4. Surface and equipment disinfection
5. X‑ray asepsis
6. Dental laboratory asepsis
7. Liability
1. MEDICAL SCREENING
Medical
screening provides information about many aspects of a patient; some of these
may alert you to premedicate or refer the patient for
specialty medical or dental care.
Medical screening may also warn you of the infectious disease status,
but not always. Remember that about 95%
of HIV‑infected individuals are asymptomatic carriers of a virus. The medical history cannot reliably detect
carriers of HIV or other pathogens (e.g., HIV and asymptomatic herpes simplex
virus (HSV) shedders or patients with high risk lifestyle behaviors.
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Specific
questions designed to help reveal HIV‑infection should be asked at the
first visit and at each subsequent appointment.
These questions should address current and chronic illnesses, lymphadenopathy, unintentional weight loss and oral
lesions. Questions should also address a
history of hepatitis or other sexually transmitted diseases.
Specific
questions should also be asked about medications (current and past), and
history of hemophilia or blood transfusion (between 1979 and 1985).
Patients
with oral and perioral conditions indicative of AIDS
such as esophageal candidiasis, Kaposi's sarcoma or
hairy leukoplakia should be referred to a physician
for evaluation. Patients with histories
such as chronic lymphadenopathy, recurrent major aphthous ulcers or oral candidiasis
should also be evaluated.
For
those patients who have contact with persons with infectious diseases, ask
follow‑up questions about the nature of the contact and refer them for
diagnostic procedures, counseling and medical follow‑up as indicated.
Remember, the medical history cannot
reliably identify all infectious patients without further testing.
The CDC and
The goal of infection control for dentistry is to block cross‑infection through use of standard/universal precautions.
What are Standard/Universal Precautions?
The CDC[1] and the
2. PERSONAL PROTECTION
One
of the most important aspects of infection control is the use of personal
protective equipment and methods. They
will protect you from infectious agents such as HIV, herpes simplex virus and
Mycobacterium tuberculosis that are transmitted by blood and saliva of dental
patients. Use the following personal
protection methods with all patients.
Specific Items
of Personal Protection
·
General
Vaccinations
Measles,
Mumps, Diphtheria, Tetanus, Pertussis, Polio,
Influenza
·
Specific
Vaccinations
Hepatitis
B, Rubella
·
Tuberculosis
testing
·
Hand
washing
·
Barriers
·
Hidden
dangers
·
Handling
sharps
A. Vaccination
Many
infectious diseases can be transmitted from dental patients to attending dental
professionals by droplets and aerosols of oral secretions. These include AIDS, hepatitis viruses, herpes
simplex, tuberculosis, measles, mumps, rubella, influenza and a number of
respiratory diseases.
Vaccinations
are available for many of these diseases.
However, currently no vaccine exists for HIV infection and AIDS. Infection control is the only protection for
dental professionals from blood- and oral secretion-borne infections in the
dental setting. Although no vaccine
exists for HIV disease, infection control would not be complete without a brief
note on vaccinations.
The
Public Health Service considers vaccines to be the ideal method for preventing
infectious diseases. Vaccines have been
developed for several infectious diseases; measles, mumps, rubella, diphtheria,
tetanus, pertussis, polio, and influenza. Because these infectious diseases can be
transmitted by droplets, they pose occupational hazards for dental professionals
whose immunity to many diseases may have declined. Vaccination records should be checked and
dental professionals should be re-vaccinated for those diseases for which they
have inadequate protection.
B. Specific
Vaccinations
1. Hepatitis B
There
are several vaccines available for immunization against hepatitis B. They offer dental and other health care
professionals protection against HBV and its sequela,
including protection against possible transmission to family members.
All
attending dentists, dental hygiene students, patient care staff, dispensary
clerks, and others who have patient contact or contact with materials that are
contaminated with blood or saliva of dental patients must take the vaccine. All personnel in these groups in the College
are required to attend an educational session on the benefits and risks of
vaccinations for hepatitis B.
2. Rubella
This
viral disease (often called German measles) is usually a mild disease in
children who suffer no sequelae. Rubella is a more serious illness in adults,
with 25 to 40% complaining of short-lived joint pain. The most serious effect of rubella is
Congenital Rubella Syndrome. CRS occurs
in the fetus whose susceptible mother becomes infected during the first
trimester of pregnancy. Severely
affected infants may have cataracts, sensorineural deafness, myocarditis, and mental retardation.
Infection
with rubella virus is acquired via the respiratory route. The virus is present in the oral secretions
of infected dental patients and others.
It is easily transmitted to a susceptible person.
A
live, attenuated rubella vaccine has been available since 1969; it is
protective in about 95% of vaccines.
Vaccination for rubella is via rubella vaccine or through a combined measles-mumps-rubella
(MMR) vaccine that provide lifelong immunity.
Students
must be vaccinated if they have not had rubella.
C. Tuberculosis
Testing
Tuberculosis
was, until the advent of modern medicine during this century, a leading cause
of death. Unfortunately, TB has shown a recent, dramatic increase in occurrence
in the
For
these reasons, the U.S. Department of Health and Human Services has recently
initiated a strategic plan for elimination of tuberculosis from this country
within the next 20 years. Drug resistant strains, which are being found in
increasing numbers, will sorely test our ability to meet this ambitious goal.
Tuberculosis
is a communicable disease that is transmitted from an infected person to an
uninfected person by respiratory secretions containing the Mycobacterium
Tuberculosis bacterium, the causative agent of the disease. Person to person
spread of tuberculosis is therefore usually through air. When people with tuberculosis of the
respiratory tract cough, airborne infectious particles are produced. If these bacteria are inhaled by other
people, an infection will almost always occur. This infection then may spread
throughout the body. Fortunately, most individuals who become infected do not
develop a clinical illness. This is because the body's immune system may bring
the infection under control; however, infected people do develop a positive
reaction to a tuberculin skin test. This
infection can persist for years, perhaps even for life. The infected person
remains at risk of developing the disease at any time, especially if the immune
system becomes impaired. Although the
disease usually affects the lung, it can occur at virtually any site in the
body.
Infection
control techniques are designed to minimize cross-infections by such pathogen
as TB, but they cannot eliminate the risk entirely. It is therefore very important for dental
professional and student dental hygienist to employ standard/universal precautions to reduce the likelihood of
acquiring a tubercular infection.
Because
TB is such a highly infectious disease and it is increasing in prevalence, all
dental personnel are required to show proof of a negative TB test. Lexington
Community College Dental Hygiene Students can be tested free of charge at
D. Hand Washing
Hand
washing is one of the most important infection control methods to reduce
cross-infection. The CDC and
The
importance of hand washing is in no way reduced by the use of gloves. Hands may be contaminated by potentially
infectious secretions of the patient through small, inherent defects in gloves
or by puncture or tear during treatment.
These holes and micro-sized pores reduce the barrier protection provided
by intact gloves resulting in contaminated hands. Because of this, it is especially important
to wash hands after degloving and after touching
inanimate objects likely to be contaminated by blood or saliva.
WHEN SHOULD HANDS BE WASHED?
·
At
the beginning of the workday, before gloving
·
Between
patient contacts, before gloving and after degloving
·
If
gloves become torn or defective
·
After
gloves are removed
·
If
hands become contaminated with blood or saliva
·
After
touching inanimate objects contaminated by blood or saliva
·
Before
leaving the operatory or laboratory
·
Prior
to leaving the office for the day
HOW SHOULD YOU WASH YOUR HANDS?
The
way in which you wash your hands and the type of detergent used are
important. Multiple cycles of washing
are more effective in removing transient pathogens and debris than a singe
cycle for the equivalent amount of time.
A two-cycle hand wash is recommended, with each cycle being
approximately 10 seconds long, increasing the time if hands are visibly soiled
or contaminated. Do not use bar soap; it
becomes contaminated and serves as a vehicle of infection. Liquid detergent dispenses are convenient.
ROUTINE
HAND WASHING
* Wet hands and wrists with warm
water.
* Apply an antimicrobial hand
washing
solution
generously.
* Lather and rub vigorously all
surfaces of
hands
and wrists for at least 10
seconds. Rinse completely.
* Lather and rub hands and wrists
for 10
seconds,
a second time.
* Rinse completely and dry hands
using a disposable,
single-use
paper towel.
CARE OF HANDS:
Avoid
hand injuries during dental procedures.
If an accidental skin penetration occurs, or gloves become torn or
punctured, remove gloves as soon as is compatible with patient's safety. Wash hands thoroughly as specified above and
re-glove prior to returning to patient care activities.
CDC
and
E. Barriers
Barrier
techniques reduce the risk of exposure to blood- and body fluid-borne pathogens
for dental health care workers as well as protect patients from possible
transmission from the worker. Barrier
techniques include gloves, masks, protective eye wear and protective clinical
attire. Chin-length plastic shields may
be worn over masks and eye wear when using the prophy
angle, cavitron and/or air-abrasive instruments.
Gloves:
The physical barrier of disposable gloves furnishes protection from potentially infectious agents. As long as the gloves are not defective and do not tear during use, they reduce the risk of exposure to blood, saliva and mucous membranes. Gloves must be worn for all patients; for all procedures; anytime there is the potential for contact with blood, saliva, or mucous membranes; or when touching contaminated objects or surfaces.
Use examination gloves for all diagnostic and therapeutic dental procedures other than surgery. Use sterile surgical gloves for all procedures where a portal of entry may be established.
Gloves should cover cuffs of long-sleeved clinic wear and wrist watches to protect bare skin from a potential exposure. Gloves should not be washed or disinfected for reuse. Detergents, disinfectants and alcohols damage glove material, causing micro pores and a tacky surface. The resulting defective gloves offer diminished barrier effectiveness. Reusing gloves presents a danger of cross-infection between patients[3].
Change
gloves between patient contacts. One
pair of gloves is usually adequate for each patient. However, gloves may need to be replaced
during lengthy procedures such as treatment in the dental hygiene clinic. To maintain barrier integrity, change gloves
at intervals less than two hours[4].
Additionally, replace gloves if a perforation is noted, after prolonged
use or following complex procedures and those procedures involving materials
that can degrade the glove.
GLOVING PROTOCOL
*
Wear gloves for all treatment
procedures.
* Remove jewelry and wash hands.
* Put on gloves. Do not wear jewelry with
gloves.
* Do not reuse gloves.
* Washing gloves is prohibited.
* Change gloves after each patient
contact;
during
lengthy or complex procedures; if
gloves
become defective; or if glove surface
becomes
tacky.
* Remove gloves and wash hands as
prescribed
after treatment.
Never
wear gloves outside cubicle or operatory for any
reason. Either don over gloves (see
following section), or remove latex gloves and wash hands before going to the
dispensary, x-ray room, patient education room, another clinic, to the restroom,
or elsewhere.
Allergies to Gloves:
If
an allergy (redness, rash, scaliness, blisters, etc.)
develops to latex or glove powder, contact the Director of Infection Control
for advice.
Over-Gloving
If
it is necessary to leave the patient briefly, to go to the dispensary, or to
handle objects such as charts, telephones, and x-rays, over gloves may be
used. Over gloves are made of
polyethylene and resemble food handler's gloves. This technique reduces the number of gloves
used, yet maintains effective infection control for safety.
Masks
Splashing
or spattering of blood and saliva commonly occurs in the practice of dental
hygiene. Because of this, wearing a mask
is essential to protect mucous membranes of the nose and mouth. At least one health care worker has been
infected with HIV as a result of a splash to the face and mouth.[5]
To
reduce potential exposures wear a mask for all patient contacts, even those
procedures perceived to have minimal potential for spatter. Change masks between patients.
Because
of the close proximity between you and the patient during treatment procedures,
a mask is easily contaminated with potentially infectious spatter. Replace a mask that has become wet. Microbes can penetrate a wet mask. A chin-length plastic face shield may be worn
over masks.
Important considerations regarding masks
* Choose a dome, ear-loop or a
tie-on mask
* Use a new mask for each patient.
* Do not reuse masks.
* Change mask if it becomes wet.
* Do not touch mask nor drape around
the neck.
Face Shields
A
chin-length plastic face shield may be worn using the prophy
angle, ultrasonic scaler and airbrasive
polisher to reduce potential spatter from these aerosols. Wash and disinfect the face shield between
patients. Refer to manufacturer's
recommendations for appropriate disinfectant.
Students may check out a face shield for use in the clinic.
Important considerations regarding face shields
·
Choose
a chin-length plastic shield.
·
Wear
always when using a prophy angle, ultrasonic scaler or air abrasive polisher.
·
Wash
and disinfect face shield between patients.
Protective Eye Wear
Protective
eye wear protects the conjunctivae and periorbital
membranes from infectious spatter. Wear protective
eye wear with all patients for all clinical procedures. Also use protective eye wear in the dental
laboratory when using equipment that creates droplets, spatter, chips or dust.
Protective
eye wear should fit closely at the bridge, brow, cheeks, and corners of the
eyes. Use large-diameter, durable and
scratch-resistant glasses with side shields.
If corrective glasses are worn, they must be of large diameter. For those who wear contact lenses or
"half glasses", over glasses with large-diameter lenses and side
shields must also be worn.
Wash
and disinfect all protective and corrective eye wear between patients using a
germicide that is EPA-registered as a tuberculocidal. Because mycobacteria
represent one of the most resistant groups of microorganisms, a mycobactericidal germicide is also effective against other
bacteria and viral pathogens. Some
disinfectants cause damage to the plastic, so refer to the manufacturer's
recommendations before using. Rinse and
dry eye wear well after disinfection.
Important considerations
regarding protective eye wear
* Wear
protective eye wear for all patient contacts.
* Use
large-diameter, durable, scratch-resistant eye wear with side shields.
* Wash
and disinfect eye wear between patients.
* All
patients must wear protective wear.
Protective Clothing
All
personnel must wear garments that protect them from droplets, spatters and
aerosols of blood or saliva of patients.
These protective garments must
cover street clothes and must not be worn outside the treatment environment.
Protective clothing may be a reusable lab coat, uniform, or gown. These garments must have long sleeves and a
high buttoned collar. Change protective
clothing at least daily, and more often if visibly soiled.
Contaminated
protective attire may be a potential source of infection. After use, place in a disposal bag before
leaving the treatment environment.
Launder garments in a standard washing machine on a normal cycle using
hot water, laundry detergent, and chlorine bleach. Dry cleaning methods also kill HIV and HBV.
Important considerations regarding protective clothing
* Wear protective clothing for all
patients.
* Change
and wash garments at least daily or more often if visibly soiled.
* Do not wear protective attire outside of the clinical environment.
* Place lab coat in plastic bag at
end of clinic session.
F. Hidden Dangers
Many seldom considered reservoirs of infection exist in and around the patient care areas. For example, infectious bacteria and viruses remain alive on dental charts for lengthy periods of time and are potentially transmissible to dental personnel and clerical staff.
Studies
at the CDC indicate that the numbers of viable HIV in blood on surfaces
decreases with time[6],
but the viability of HIV on surfaces is generally just a few hours. On the other hand, other viruses such as HBV,
can remain alive for up to six months on surfaces. Although HIV and HBV remain viable for
varying amounts of time, no viral transmission for a contaminated surface has
been documented[7].
However,
avoid eating, drinking and smoking around materials or supplies that may be
suspect to hidden contaminants. This
includes morning coffee, lunch and afternoon snacks at the reception desk or in
the dental laboratory.
Hidden
sources of contamination include dental charts, and pens and pencils.
Dental charts
Prevent
contamination of dental charts before the fact, rather than attempting to
decontaminate charts afterward. Place
the patient evaluation form (buff-colored) in a plastic protective cover before
inserting in the chart. The form is to
stay in the plastic protective cover for a minimum of six months from the time
the last recording was entered on the form.
Important
considerations regarding the handling of dental charts
* Avoid handling dental charts with
contaminated hands, either gloved or bare.
* Before handling the chart during
treatment, over glove or remove gloves and wash bare hands. Alternatively, ask
non-treatment personnel to handle charts.
Pens and pencils.
Writing
instruments are easily contaminated with oral secretions that are potentially
infectious.
Important considerations regarding the
handling of writing instruments
* Use and label pens and pencils with
colored tape for operatory use only.
* Clean and disinfect writing
instruments used in patient care areas after each patient.
* Avoid hand to mouth pathways. Never
place a writing instrument in your mouth.
* Do not offer your pens and pencils
to clinical instructors.
G. Handling
Sharps
Any
item that could puncture the skin such as, needles, scalpel blades, explorers, curets, burs or orthodontic wires are considered
sharps. Sharps are contaminated and
potentially infectious. Handle all
sharps carefully and place disposable sharps, for example, needles, scalpel
blades and orthodontic wires in a sharps container after use. While the emphasis of a sharps discussion is
needles safety, other items with sharp tips or cutting edges also pose a threat.
Needle sticks constitute the most common type of occupationally-acquired exposure in the health care field