INFECTION CONTROL IN
DENTAL
HEALTH-CARE SETTINGS.
TULSA, OKLAHOMA (USA) – 2013
A dental practice run by Dr W. Scott Harrington was investigated after a
patient tested positive for hepatitis C.
Public health officials found unsafe injection practices, rusty
instruments, and poor sterilization procedures.
Nearly 7,000 patients were advised to get tested for HIV,
hepatitis B, and hepatitis C.
Outcome:
At least 89 patients tested positive for Hepatitis C, 5 + Hep B, 4 +
HIV )
Dr Harrington surrendered his license.
It highlighted the dangers of reusing needles and failing to
autoclave instruments properly.
ENGLAND – 2014 (NOTTINGHAMSHIRE)
A dentist, Desmond D’Mello, was secretly filmed failing to
wash hands between patients, reusing dirty gloves, and
not sterilizing equipment properly.
This triggered one of the largest NHS patient recall
campaigns, involving 22,000 patients.
Outcome:
He was suspended and later removed from the dental register.
It raised awareness of how basic lapses in hygiene can
endanger thousands.
WHAT IS INFECTION CONTROL?
The techniques and methods used to reduce the
number of infectious agents in the dental
practice environment.
To prevent or reduce the likelihood of
transmission of the infectious agents from one
person, item/ location to another.
And to make and maintain items and areas free
from infectious agents as much as possible.
WHY IS INFECTION CONTROL
IMPORTANT IN DENTISTRY?
Both patients and dental health care personnel
can be exposed to pathogens.
Contact with blood, oral and respiratory
secretions, and contaminated equipment occurs.
MODE OF TRANSMISSION
Direct contact from one person to another;
Indirect contact via instruments and equipment, and
droplets or aerosol/spray.
The microorganisms can gain access to the body through
what is known as ‘portals of entry’.
Inhaled
Implanted
Ingested
Injected
Splashed onto skin or mucosa
WHAT CAN BE DONE…
The spread of micro-organisms can be reduced
by:
Limiting surface contamination by the micro-
organisms;
Adhering to good personal hygiene practices
Using personal (barrier) protection
Using disposable products as much as possible
(e.g., paper towels)
Undertaking risk minimization techniques.
STANDARD PRECAUTIONS /
UNIVERSAL PRECAUTIONS
Standard precautions minimize the risk of transmission
of infection from person to person
They are essential for the care and treatment of all
patients regardless of their perceived or confirmed
infectious status.
They are essential in handling blood (including dried
blood), saliva, and other body fluids, whether
containing visible blood or not, and when touching
non-intact skin or mucous membranes.
ELEMENTS OF STANDARD PRECAUTIONS
1) Hand hygiene.
2) Personal protective measures
3) Surgical procedures and aseptic technique
4) Management of sharps
5) Management of clinical waste
6) Environment cleaning and barriers
7) Cleaning blood spill
8) Management of spill
1. HAND HYGIENE
WHY IS HAND HYGIENE IMPORTANT?
Reduces the number of infectious microorganisms on
the skin
The single most important measure of infection
control in dental surgery.
Hands are the most common mode of pathogen
transmission
HANDS NEED TO BE CLEANED WHEN
Visibly dirty
Before and after food
After touching contaminated objects with
bare hands
Before and after patient treatment
Before wearing gloves & after removal
HAND WASHING.
Hand washing
Washing hands with plain soap and water
Antiseptic(antimicrobial) hand wash/soap
Washing hands with water and Antiseptic soap
Surgical scrub in OT
Alcohol-based hand rub
Decontaminating hands using alcohol-based gels or
liquids (also known as waterless hand washing) before
and after every patient contact
HAND-WASHING AND HAND
DECONTAMINATION
Hand washing should be undertaken in dedicated
(clean) sinks, preferably fitted with non-touch taps
Not in the (contaminated) sinks used for instrument
cleaning.
If touch taps are used, the taps may be turned on
and off with a paper towel.
HAND CARE
Hands must be well cared for & protected against
dryness.
Lacerated or cracked skin can allow entry of micro-
organisms, therefore, any cuts or open wounds need to
be covered with a waterproof dressing.
All hand, wrist, or nail jewelry, artificial nails, promote
significant growth of skin micro-organisms.
All fingernails must be kept short to prevent glove tears
and allow thorough hand cleaning.
2) PERSONAL PROTECTIVE
EQUIPMENT
PERSONAL PROTECTIVE
EQUIPMENT
A major component of Standard Precautions
An important way to reduce the risk of transmission of
infectious agents.
Protects the skin and mucous membranes from
exposure to infectious materials where aerosols are
likely to be generated in spray or spatter
PERSONAL PROTECTIVE
EQUIPMENT
Dental care providers and dental staff SHOULD be
provided with all appropriate and necessary protective
clothing and equipment for the procedures.
Educate on how to use them correctly.
Removed when leaving the work area.
FACE MASK
The most common causes of airborne aerosols are
the high speed air rotor handpiece, the
ultrasonic scaler and the triplex syringe.
Aerosols of 3μm or less in size
The aerosols produced may be contaminated with
bacteria from the oral cavity (saliva and dental
plaque), as well as viruses from the patient’s blood.
Wear a surgical mask… fluid-repellent paper filter
masks
EYE PROTECTION
Eyewear must be optically clear, anti-fog, distortion-
free, close-fitting, and shielded at the sides.
Patients must be provided with protective eye
equipment to minimize the risk of possible injury
from materials or chemicals used during treatment.
GLOVES
Latex gloves
Neoprene or nitrile gloves
Not a substitute for hand washing!
Heavy-duty utility, puncture-resistant gloves must be
used during instrument cleaning..
RECOMMENDATIONS FOR GLOVING
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
PROTECTIVE CLOTHING
Wear gowns, lab coats, or a uniform
The most suitable type of gown is an
impermeable gown.
Protective footwear- enclosed footwear
for protection against accidental drop or
spill
3. SURGICAL PROCEDURES AND
ASEPTIC TECHNIQUE
The principles of sterile aseptic technique must be
applied to all surgical procedures undertaken in the
oral health care setting.
From a dental perspective, this would include a
mucosal incision, surgical penetration of bone, or
elevation of a mucoperiosteal flap.
4. MANAGEMENT OF SHARPS
There is a risk of a penetrating injury to the
dental care provider, with the subsequent
possibility of exposure of the patient to the
blood of the dental care provider
Inappropriate handling -penetrating injuries
MANAGEMENT OF SHARPS
Sharp instruments such as scalpels and scalers must
never be passed by hand
Placed in a puncture-resistant tray or bowl
Carried from the surgery to the sterilizing area in a
lidded puncture-resistant sharps transport container.
Needles must not be re-sheathed unless an approved
recapping device or single-handed technique is used.
Contaminated needles must never be bent or broken by
hand or removed from disposable syringes.
DISPOSING OF SHARPS
Used disposable needle syringe combinations,
needles, scalpel blades, orthodontic bands, burs, and
other single-use sharp items must be discarded in
clearly labeled, puncture and leakproof
containers
A separate sharps container
Sharps containers must be sealed when they are
three-quarters full
5. MANAGEMENT OF CLINICAL
WASTE
Separate medical or non-medical waste at the point
of generation
Use color-coded and labeled containers
Dispose of Wastes containing human tissue in
yellow containers bearing the international black
biohazard symbol and marked medical waste.
PPE must be used when handling medical waste bags
and containers.
MEDICAL WASTE
General medical waste
Infectious/biohazard waste- blood, contaminated
equipment, IV tubing
Hazardous medical waste-bulk chemo
Radioactive medical waste-lab research liquids, or
anything contaminated by radiotherapy
WASTE DISPOSAL
Incineration
Integrated sterilizer and Shredder
Waste dump
6: ENVIRONMENT CLEANING AND
BARRIERS
ENVIRONMENTAL CONTROL
A range of environmental controls can be used to
reduce the risk of transmission of infectious agents
in dental practice.
Care must be taken to avoid contaminated
instruments/equipment re-entering clean work
areas.
Floor coverings- non-slip and impervious.
Avoid Carpet.
Computer keyboards -covered
Lunchroom crockery must not be washed in
the hand or instrument wash basins.
Food must not be stored in a refrigerator
with dental materials, sealed clinical
specimens, or medicines.
Housekeeping/environmental surfaces- clean once a
week
Use detergent and water.
Clinical contact areas –clean after every patient
Non-critical instruments and devices: Clean and
disinfect
Examples: X-ray heads, face bows, pulse oximeter,
blood pressure cuff
CLINICAL CONTACT SURFACES
SURFACE BARRIERS
HOUSEKEEPING SURFACES
7. CLEANING BLOOD SPILLS
If blood is spilled, it must be cleaned up as soon as
possible.
Wipe the area immediately with a paper towel and
then clean with water and detergent.
WATERLINES AND WATER
QUALITY
Most dental unit waterlines contain biofilm, which acts
as a reservoir of microbial contamination
Must be fitted with non-return (anti-retraction) valves
Air and waterlines from any device connected to the
dental water system that enters the patient's mouth
must be flushed for a minimum of two minutes at the
start of the day and for 30 seconds between patients
STERILIZATION AND DISINFECTION
METHODS
1. Moist heat
Steam under pressure (AUTOCLAVING)
Autoclaves commonly use steam heated to 121–
134 °C (120 approx.) for 30 mins.
Steam sterilization -effective, fast, safe, and affordable
Non-toxic and safe
2. Dry heat
Removes moisture content from coatings and other
materials.
Proper dry heat sterilization, increased time, and
higher temperatures (approx. 180 degrees Celsius) are
necessary.
Time-consuming but less expensive
3. Chemical vapor
Unsaturated chemical-vapor sterilization involves heating a
chemical solution, primarily alcohol with 0.23%
formaldehyde, in a closed, pressurized chamber.
This method causes less corrosion of carbon steel instruments
(e.g., dental burs) than steam sterilization because less water is
present during the cycle
4. Ethylene oxide gas
Reacts in a way that disrupts cell growth and division,
resulting in the killing of the microorganisms.
Toxic for humans
Disinfection
Disinfection describes a process that eliminates many or all pathogenic
microorganisms, except bacterial spores, on inanimate objects
Chemical :
Chlorine, ozone, halogens, bromine and iodine, and bromine chloride,
copper and silver, phenol and phenolic compounds, alcohols,
quaternary ammonium salts, hydrogen peroxide, etc, are primary
methods for disinfection.
Physical
ultraviolet light (UV), electron beam, gamma-ray irradiation,
sonification, and heat
PREPARATION AND PACKAGING
Critical and semi-critical items that will be stored
should be wrapped or placed in containers before
heat sterilization
Hinged instruments opened & unlocked
Place a chemical indicator inside the pack
Wear heavy-duty, puncture-resistant utility gloves
STERILIZATION MONITORING
TYPES OF INDICATORS
Mechanical
Measure time, temperature, pressure
Chemical
Change in color when physical parameter is
reached
Biological (spore tests)
Use biological spores to assess the
sterilization process directly
BLOOD AND BODY FLUIDS
PROTOCOL
EYE / MUCOSAL SPLASH OR
SPRAY
Immediately flush the mucous membrane
/conjunctiva with normal saline or running water
If contact lenses are worn, remove after flushing eyes
and clean as usual
Further management depends upon the nature of the
wound.
NEEDLE STICK INJURY / SHARP
EXPOSURE
First aid
Stop work immediately, regardless of the situation…
Allow the wound to bleed and clean it thoroughly with soap
and lukewarm water
Assessment and record of the type of injury, type of patient,
and the doctor
Baseline tests: HIV antibody, HCV antibody, and antibody
to Hepatitis B surface antigen (anti-HBs).
EXPOSURE PROTOCOL
Give a single dose of Hepatitis B immunoglobulin
(HBIG) within 48-72 hours
Start a course of HBV immunization- 0,1,6
If the injured staff member has ever had a blood test
that demonstrates Hepatitis B immunity (anti-HBs
antibodies > 10 IU/mL) – whether from vaccination or
past infection – they are protected, and there is no
need for Hepatitis B immunoglobulin after a potential
or confirmed exposure to Hepatitis B.
ASSESSMENT AND RECORDS
A full record of the incident should be made, including details of:
Who was injured? * How the incident occurred.
The type of exposure;
The presence of visible blood on the device, causing the injury;
Whether a solid, sharp object, a hollow bore object, or a needle was
involved;
The gauge of the needle;
The time the injury occurred;
What action was taken? *Who was informed and when
The details of the patient being treated.
INFLUENCING FACTOR
Factors which influence whether an exposure has the
potential to transmit a blood-borne virus (BBV) infection
include:
The type of exposure (mucosal splash vs a deeply
penetrating skin injury);
The type of body substance (e.g., how much blood is
present in the saliva);
The volume of blood or body fluids;
The length of time in contact with blood or body fluids;
The time that has elapsed since the exposure.
FINAL ASSESSMENT
To complete an accurate assessment after a sharps injury, the following
factors should be considered: •
the type of device involved; •
the procedure for which the device was used (e.g., into a vein or
artery); •
whether the injury was through a glove or clothing; •
whether a deep injury occurred in the exposed person
whether the source patient is viremic (e.g., with advanced/terminal HIV
disease or a high viral load).
COUNSELLING AND FOLLOWUP.
SOURCE NEGATIVE FOR HEPATITIS B
If blood tests show that the source patient is
negative for HIV, HBV, and HCV, no further follow-up
of the exposed staff member is generally necessary
Unless there is reason to suspect the source person
is seroconverting to one of these viruses(window
period)
Or A high risk of blood-borne viral infection at the
time of the exposure (because they have recently
engaged in behaviors that are associated with a risk
for transmission of these viruses).
The window period causes a FALSE NEGATIVE test result.
The patient may be infectious, but this is undetectable
by testing.
The window period for HIV is usually three months or
longer.
The polymerase chain reaction (PCR) testing for HIV/viral
RNA can identify 90% of infections within four weeks,
significantly reducing this window period.
The window period is six months for Hepatitis B and
Hepatitis C.
SOURCE POSITIVE FOR HEPATITIS
B
If the source is KNOWN or SHOWN to be positive for
Hepatitis B surface antigen (HBsAg), the level of
antibodies is important.
If the staff member is immune to Hepatitis B (anti-
HBs antibodies > 10 IU/mL), they are protected.
If levels of immunity are relatively low (i.e., between
10 and 100 IU/mL), a booster injection is given.
If the staff member is NOT IMMUNE (e.g., has never
been immunized, did not seroconvert to the vaccine (a
non-responder), or has antibody levels to HBsAg less
than 10 IU/mL), the correct treatment is to:
1. Give a single dose of Hepatitis B immunoglobulin (HBIG) within
48-72 hours
2. Start a course of HBV immunization.
3. HBV vaccine should be given within seven days of exposure, and
then repeated at 1-2 months and again at six months after the
first dose.
Following the final vaccine dose, the level of immunity (antibodies
to surface antigen) should be checked 2-4 weeks later.
Risk of transmission
6.3% if the source is Hepatitis B antigen negative
More than 30% if the source is Hepatitis B antigen positive.
SOURCE POSITIVE FOR HEPATITIS
C
If the source is KNOWN or SHOWN to be positive for antibodies to
Hepatitis C, there is no effective post-exposure prophylaxis (PEP) for
Hepatitis C.
Hepatitis C is treated using direct-acting antiviral (DAA) tablets, 8-12 weeks.
DAA tablets are the safest and most effective medicines for treating hepatitis C.
They're highly effective at clearing the infection in more than 90% of people.
Risks of transmission after a sharps injury from a positive source
1.8–3.1% of the source is PCR negative
10% if the source is PCR positive.
Follow up
HCV antibodies -3 and 6 months, liver function tests -2,3 and 6 months
SOURCE POSITIVE FOR HIV
Risk of transmission
0.3 % - after a sharps injury with HIV-infected blood
0.09% - after a mucous membrane exposure to HIV-
infected blood
HIV PEP is typically two or three orally administered
anti-retroviral drugs and should be administered to the
recipient within 24-36 hours after exposure (and
preferably within two hours).
This therapy should be continued for four weeks, on
the advice of an infectious diseases physician.
ASSIGNMENT
Write down the exposure protocol / action plan for
exposure to
1. Needle stick injury
2. Mucosal splash to the eye.
Discuss the virulence of hepatitis B, C, and HIV in case
source positive and source negative (for each virus)
THANK YOU.
