PRACTICAL GUIDE

INFECTION CONTROL FOR THE DELIVERY OF BASIC ORAL EMERGENCY CARE

assistant places the sharp instrument in a disinfected basin do not add any more water or instruments during the process.
or tray, informs the oral health worker of its presence and
Another alternative to high level disinfection by boiling in water is to
INFECTION CONTROL
then the oral health worker can remove and use it.
submerge the cleaned instruments in a bowl of 0.5% bleach
• Using the ‘single-handed technique’ if it is necessary to solution for 20 minutes. Remove the instruments and other items
recap needles. Place the cap on a flat surface. With one
hand to hold the syringe and use the needle to scoop the
using high level disinfected forceps. Rinse well with boiled water to
remove the residue left behind from the chemicals as this is irritating
FOR THE DELIVERY OF BASIC
cap up. When the cap is covering the needle completely,
use the other hand, holding the cap at the base near the
to the skin and tissues if not removed. A fresh solution of bleach
must be prepared daily and thrown out at the end of the day.
ORAL EMERGENCY CARE
hub, to secure the cap firmly onto the hub of the needle.
BY ROBERT YEE
PROPER MANAGEMENT
OF PATIENT CARE ITEMS
Formula For Preparation of
Cleaning of dirty instruments 0.5% Bleach Solution
All instruments used in the treatment Using Liquid Bleach: INTRODUCTION
process need to be scrubbed with % chlorine in liquid bleach - 1 = Total parts of water
soap and water. A new solution of for each part of bleach
One of the components of the Basic Package of Oral Care1 is Oral Urgent Treatment
% chlorine desired
detergent and water must be (OUT). Primary health care workers can be trained to provide basic emergency care Correspondence to:
e.g. 5% - 1 = 9 parts of water to 1 part of bleach Dr. Robert Yee
prepared daily, more often if very including the extraction of badly decayed or periodontally involved teeth in Director Oral Health Programme
dirty. Always wear utility gloves, 0.5% United Mission to Nepal
underserved communities. In meeting the perceived needs and treatment demands Kathmandu
apron, mask and glasses when
Using Bleach Powder: of the community, primary health care workers need to be trained to provide quality Email: [email protected]
cleaning the instruments and other
items. Using a soft scrubbing brush or toothbrush scrub the % chlorine desired x 1000 = Number of grams oral care with minimal equipment and supplies in a simple setting. An important
instruments and other items well to remove all organic material % chlorine in bleach powder of powder for each element of quality care is the protection of the patient, the oral health care worker,
litre of water
(blood and saliva) and dirt. This should be done beneath the ancillary staff and the community from infections that
surface of the water as this reduces splashing. All surfaces of the e.g. 0.5% x 1000 = 14.3 grams of sodium may originate from the health care setting, through the Susceptible Host Reservoirs
instruments and items must be scrubbed. Special care must be 35% hypochlorite powder for implementation of effective infection control practices. Dentist Assistant People Water
taken to ensure that all joints and grooves are scrubbed well. every litre of water Primary Health Care Work Solutions Waste
Storage of instruments The intention of this practical guide is to assist oral Housekeeping Instruments
Community Equipment
It is necessary to rinse all items after cleaning with either clean health workers in their practice of infection control
After sterilisation or high level disinfection, unwrapped
running water or a bowl of clean water (changed regularly) to in a resource limited setting.
instruments are either used immediately or stored in a sterilised or
remove all detergent solution and then dried with a clean towel.
high level disinfected container clearly marked to indicate that the
Sterilisation instruments have been sterilised or high level disinfected. The DISEASE TRANSMISSION Places of Entry
Broken skin
Infectious
Places of Exit
Agents
instruments should be stored in an enclosed area (e.g. cupboard, Puncture wound Bacteria Breathing Skin
Instruments with joints such as extraction forceps should be When pathogens are introduced to the human body or when Surgical site Mouth
drawer, container) and used again within one week. Virus
opened prior to placement in the steriliser. They should be placed normal flora are introduced to another part of the body, Eyes Mouth Fungi
so that the steam will be able to circulate freely around them. If a infectious disease can result. Infections are transmitted from
pressure cooker is used the instruments should be placed on a person to person through the disease-transmission cycle (Figure
FURTHER INFORMATION 1). Micro organisms survive, grow and multiply in a reservoir and
rack above the above the water level.
For more comprehensive information on infection control for primary Modes of
are transmitted through a place of exit before spreading to a Transmission
Maintain a temperature of 121ºC (250ºF) at 15 pounds of health care workers involved in the delivery of basic oral care, please susceptible host through a place of entry. Direct contact
pressure for 20 minutes for unwrapped instruments and 30 refer to “Infection Control Policy And Procedures For The Delivery Of Indirect contact
A Basic Package Of Oral Care In Nepal”, available from the United There are four modes by which infections are spread in the
minutes for wrapped instruments. Droplet transmission
Mission to Nepal Oral Health Programme: [email protected].
dental environment: Airborne
Begin timing when the steam is released and then turn the heat
down low still ensuring that steam is still released from the valve. REFERENCES • Direct contact - contact with micro organisms at the
After the end of the sterilisation process, release the steam and 1. Frencken JE, Holmgren CJ and van Palenstein Helderman WH. source, e.g., the patient’s mouth.
open the lid of the pressure cooker slightly, allowing the Basic Package of Oral Care. Nijmegen: WHO Collaborating Figure 1. The disease-transmission cycle2.
Centre, 2002. • Indirect contact - contact with inanimate materials, e.g.,
instruments to cool slowly.
2. AVSC International (now EngenderHealth). Infection Prevention contaminated instruments, items, and surfaces.
High level disinfection Curriculum – A Training Course for Health Care Providers and
other Staff of Hospitals and Clinics – Trainers Manual. New York, • Droplet transmission - spray or splatter containing micro
Whenever possible, instruments which have penetrated bone or USA: EngenderHealth, 1999. organisms settling on mucous membranes. PLANNING FOR INFECTION CONTROL
soft tissue or have been in contact with blood should be sterilised. 3. TAFE Commission. Learning Guide Dental Hygiene and Safety In order to minimise the spread of contaminants and risk of
4399E. New South Wales, Australia: Community Services, Health, • Airborne – inhalation of evaporated droplets containing
If a pressure cooker or autoclave is not available, instruments may disease transmission, forethought and action should be taken to:
Tourism & Hospitality Division of TAFE NSW, 1999. micro organisms that remain in the air, i.e., aerosols.
be high level disinfected by boiling in a pot of water for 20
4. EngenderHealth. Infection Prevention – "A reference booklet for • Control access to the operating area.
minutes after proper cleaning with soap and water. 20 minutes is health care providers” New York, USA: EngenderHealth, 2000. The easiest way to break the disease-transmission cycle is to
timed when the water begins to boil. Once the pot begins to boil follow appropriate infection control practices. • Clean all surfaces which may come in contact with dental

For more information on infection control refer to: OSAP – This guide can be photocopied and used whenever needed. Copyright remains with the FDI.
Developing Dentistry ■ Volume 7 No.1 2006 Organization for safety and asepsis procedure. www.osap.org Reproduction for educational purpose is allowed without prior permission from the FDI. For all other purposes written permission must be obtained.
Please contact [email protected]
The paper expresses the views of the author but not necessarily those of the FDI World Dental Federation.
 PRACTICAL GUIDE

INFECTION CONTROL FOR THE DELIVERY OF BASIC ORAL EMERGENCY CARE

instruments. If possible cover • Hand hygiene

the surface with clean material Proper technique for washing of hands (ensure hands are held higher than the elbows)
• Personal protective equipment
which can be changed
between patients. • Controls to prevent injuries

• Clearly establish areas • Proper management of patient care items and

designated for ‘clean’ items environmental surfaces
such as supplies, materials and
sterilised instruments; and
‘dirty’ items (i.e. items and IMMUNISATION
materials which have been in
Oral health worker and anciliary staff should be immunised Step 1 Apply cleansing agent, Step 2 Rub palms over backs Step 3 Rub palms together Step 4 Link fists together and Step 5 Wash thumbs in palms Step 6 Rub tips of fingers
contact with blood, saliva or lather hands and wrists of palms. with fingers linked. rub backs of fingers in in a circular motion. across palms
or receive boosters against common infections: Tetanus,
mucous membrane). using rotary motion. a circular motion.
Diptheria, Poliomyelitis, Typhoid, Meningococcal, Hepatitis
• Set up a flow pattern for A, Hepatitis B, Rubella, Tuberculosis, Measles, Whooping
Figure 2. Effective handwashing technique2. Note: Wash hands and wrists for a minimum of 15 seconds
instrument processing: cough, Mumps.
moving from reception of
contaminated instruments,
cleaning, packaging, sterilisation/high level disinfection, HAND HYGIENE PERSONAL PROTECTIVE EQUIPMENT washing the hands. After drying of the hands, pick up one glove
and storage. by the cuff and place the opposite hand inside the glove, carefully
Personal protective equipment (PPE) provides a barrier between pulling the glove over the hand. Then pick up another glove by
Handwashing is the single most important procedure for
• Set up the treatment area with necessary treatment the patient’s blood and body fluids and the oral health worker’s
preventing infections. Oral health workers should wash all the cuff using the gloved hand and repeat the process.
instruments and materials before commencement of skin, eyes, nose and mouth. The types of personal protective
surfaces of their hands with soap and running water for at least
treatment. This includes pre-dispensing cotton gauge and equipment include: After the treatment has been completed and the dirty instruments
15 seconds after touching anything that may be contaminated;
filling syringes with local anaesthetic solution prior to have been taken away, remove the contaminated gloves by
before and after wearing gloves for examination, treatment and • Medical gloves to be worn whenever oral health care
treatment. grabbing the outside of the cuff and pulling downwards turning
instrument processing procedures; and after using the toilet or workers are performing duties which potentially bring the glove inside out and away from the hands. Once the glove is
• If multi-dose vials of local anaesthetic are used, always latrine (Figure 2). If drinking quality water is not available, an them in contact with blood or other body fluids. The off the hand, place the ungloved fingers inside the cuff of the
use a new needle and syringe each time a solution is alcohol hand rub may be used for 15 seconds until the hands are gloves should be changed between patients. It is remaining glove and remove the glove turning it inside out and
drawn and never leave needles inserted in the vial cap. dry. An alcohol hand rub is only effective when the hands are not advisable that gloves not be washed, disinfected or downwards. When other protective personal equipment are
• Cover instruments and surfaces which might become soiled. Some general notes on hand hygiene: sterilised again. However, in resource limited settings, removed, avoid touching the contaminated areas. Always wash
contaminated. surgical gloves may be steam sterilised after washing and dry hands before regloving.
• Before washing hands finger rings, watches and other
• Proper disposal of contaminated wastes and needles by and checking for holes 4.
wrist jewellery should be removed.
incineration or burial.
• Nails should be kept short and clean. • Masks to prevent potential infection by aerosol CONTROLS TO PREVENT INJURIES
contamination and splashes from the patient and vice
• Do not use fingernail polish or artificial nails as these can Sharp instruments used in the delivery of oral care (e.g. explorers,
versa. The mask should fit well over the face creating a
trap bacteria and make dirt hard to see beneath the nails. needles, glass cartridges or broken anaesthetic ampules) have the
Between patients: seal over the mouth and nose. A mask will lose its
potential to cause injury and spread infectious diseases.
• Always use running water. If this as not available then protective quality once it becomes wet; therefore, a
• Clean surfaces that have been used; tables, chairs and one of the following should be used: mask should be changed when it becomes wet from Injuries can be prevented by:
benches 0.5% chlorine solution wearing utility gloves.
• A closed bucket with a tap. splatter on the outside or from condensation on the
• Clean all blood spills using a cloth and 0.5% chlorine inside. Avoid touching the outside of a contaminated • Minimum handling of
solution. • A bucket and a jug, where one person pours whilst mask during and after treatment. hypodermic needles, syringes
another washes. and other sharp instruments
• Contaminated containers may be disinfected using 70% • Protective eyewear to prevent potential infection by
• Drying hands well reduces the number of after use.
alcohol or 0.5% bleach solution. aerosol contamination and splashes. The eyewear
microorganisms. Hands should be dried with a clean • Using great care when
should be decontaminated with soap and water and
towel or allowed to air-dry before putting on gloves. handling sharp instruments.
disinfected between patients.
Clean towels should be provided twice daily and changed
STANDARD PRECAUTIONS • Protective clothing to prevent contamination of street
• Disposing of disposable sharp
more frequently if they become contaminated or soiled.
instruments/items in puncture
As the infectious status of the patient is often unknown, to clothes and protection of skin from blood and body
resistant containers
prevent contamination and cross infection either to other fluid contamination. The protective apparel should be
immediately after use, or as soon as possible. When the
patients or to the oral health care worker, it is necessary to treat TO MAKE ALCOHOL HAND RUB changed when it becomes soiled.
container is ? full, it is carefully removed and incinerated
all patients as potentially infectious and standard precautions • Puncture resistant utility gloves to protect the hands or filled with plaster or cement and buried.
Mix:
should be implemented. ‘Standard Precautions’ are work and forearms during the processing of instruments and
practices, which require everyone to assume that all blood, body • 2ml of glycerine with • Always wear utility gloves when washing sharp
for cleaning procedures which may involve contact with instruments.
fluids (except sweat), mucous membranes and non-intact skin are • 100ml of 70% alcohol blood and body fluids.
potential sources of infection. ‘Standard Precautions’ are work • If sharp instruments need to be passed between the oral
practices required for the basic level of infection control and Before delivering patient care put on the protective clothing, then health worker and assistant during treatment then they
include the following measures: the surgical mask, and thereafter the protective eyewear before must never touch the instrument at the same time. The

Developing Dentistry ■ Volume 7 No.1 2006