Hospitals, dental facilities, and other healthcare clinics are places where exposure to risk of infection is at a high level. Infection control is essential to prevent nosocomial or healthcare-associated infection and is an integral part of the clinic staff responsibilities.
In fact, infection can be transmitted through different ways, whether patient-to-patient, from patients to staff and from staff to patients, or among-staff.
• Hand hygiene
• Use of personal protective equipment (gloves, gowns,…)
• Prevention to percutaneous injuries
• Environmental cleaning
• Sterilization and decontamination of patient-care items
1- Hand Hygiene:
The first and most important and effective preventing measure to infection transmission is proper hand hygiene.
Hand hygiene includes hand washing (with antimicrobial soap and water) and alcohol-based hand rubs.
It is mandatory for the dentists and the assistant to wash their hands before touching a patient (even if they will be wearing gloves), and after removing the gloves.
This measure is taken for routine dental examinations, nonsurgical and surgical procedures.
2- Personal protective equipment:
Dentists are highly exposed to blood borne pathogens due to the use of rotary dental and surgical instruments and air-water syringes.
This daily-use instrumentation produces a visible spray that contains large particle droplets of water, saliva, blood, microorganisms and other debris. Hence, the risk from exposure to infectious agents is high.
Protective personal equipment is wearable equipments that protect the dentist from infectious exposure. It includes gloves, face masks and protective eyewear that should be worn during each procedure. Protective clothing such as gowns should be worn during surgical activities to protect the skin from blood and body substances.
Sterile gloves are not absolutely necessary in routine tooth extractions. However they are indispensable during other surgical procedures because they minimize transmission of microorganisms from the dentist’s hand to patients and prevent contamination of the surgeon with the patient’s blood.
Protective personal equipment should be removed before leaving the patient’s room and never have to be washed for the purpose of reuse (gloves, gowns…).
3- Prevention of percutaneous injuries:
Infectious exposure occurs too through percutanuous injuries (syringe needles, burs, sharp instruments) which induce the highest risk of transmission.
After their use, needles and other sharp instruments must be placed in appropriate puncture-resistant containers placed in every dental room, avoiding to carry them to other rooms and minimizing possible injuries.
Used needles should be recapped using the one-handed scoop technique and never be directed toward any part of the body.
Dentists should never bend or break the needle and if a procedure involves multiple injections the dentist must recap the single needle between each injection.
In case of puncture wounds or other injuries, the skin should be washed with soap and water.
No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of blood borne pathogens transmissions.
The use of antiseptic is not contraindicated but the application of caustic agents such as bleaching agents is not recommended.
After a wound injury or infection exposure, practitioners should immediately report the exposure and fill a complete exposure report:
• Date and time of exposure.
• Details of the procedure being performed, including where and how the exposure occurred and whether the exposure involved a sharp device, the type and brand of device, and how and when during its handling the exposure occurred.
• Details of the exposure, including its severity and the type and amount of fluid or material. For a percutaneous injury, severity might be measured by the depth of the wound, gauge of the needle, and whether fluid was injected; for a skin or mucous membrane exposure, the estimated volume of material, duration of contact, and the condition of the skin (e.g., chapped, abraded, or intact) should be noted.
• Details regarding whether the source material was known to contain HIV or other blood borne pathogens, and, if the source was infected with HIV, the stage of disease, history of antiretroviral therapy, and viral load, if known.
• Details regarding the exposed person (e.g., hepatitis B vaccination and vaccine-response status).
• Details regarding counseling, post exposure management, and follow-up.
Each occupational exposure should be evaluated individually for its potential to transmit HBV, HCV, and HIV, based on the following:
• The type and amount of body substance involved.
• The type of exposure (e.g., percutaneous injury, mucous membrane or non-intact skin exposure, or bites resulting in blood exposure to either person involved).
• The infection status of the source.
• The susceptibility of the exposed person
4- Environmental cleaning:
In the dental operation room, environmental surfaces (i.e., a surface or equipment that does not contact patients directly) can become contaminated during patient care. Certain surfaces, especially ones touched frequently (e.g., light handles, unit switches, and drawer knobs) can serve as reservoirs of microbial contamination, although they have not been associated directly with transmission of infection to either Dental health-care personnel or patients. Transfer of microorganisms from contaminated environmental surfaces to patients occurs primarily through DHCP hand contact. When these surfaces are touched, microbial agents can be transferred to instruments, other environmental surfaces, or to the nose, mouth, or eyes of workers or patients. Although hand hygiene is key to minimizing this transfer, barrier protection or cleaning and disinfecting of environmental surfaces also protects against health-care associated infections. It is essential to establish policies and procedures for routine cleaning and disinfection of environmental surfaces and to focus on surfaces in proximity to the patient and that are frequently touched. Detergents and disinfectants are labeled for use in healthcare facilities.
5- Sterilization and disinfection of patient-care items:
Patient-care items (dental instruments, devices and equipment) are categorized as critical, semi-critical or noncritical, depending on the potential risk for infection associated intended use.
Infection-control categories of patient-care instruments
Dental Instrument or item
|Penetrates soft tissue, contacts bone enters into or contacts the bloodstream or other normally sterile tissue.||Surgical instruments, periodontal scalers, scalpel blades, surgical dental burs.|
|Contacts mucous membranes or non-intact skin; will not penetrate soft tissue, contact bone, enter or contact the bloodstream or other normally sterile tissue.||Dental Mouth mirror, amalgam condenser, reusable dental impression trays, dental hand pieces.|
|Contacts intact skin.||Radiograph head/cone, blood pressure cuff, face bow, pulse oximeter|
The instruments processing area is divided into 4 sections:
- Receiving, cleaning, decontamination
- Preparation and packaging
a- Receiving, cleaning and decontamination:
The process begins with cleaning instruments and removal of debris as well as organic and inorganic contamination by scrubbing with a surfactant, detergent and water or an ultrasonic cleaner with chemical agents or washer-disinfector.
After cleaning, instruments should be rinsed with water to remove chemical or detergent residue.
Using a automated cleaning equipment (ultrasonic cleaner or washer-disinfector) improve cleaning effectiveness and decrease worker exposure to blood and body fluids, making the cleaning process safer.
b- Preparation and packaging:
Once the instruments are cleaned and decontaminated, they are packaged for sterilization. An internal chemical indicator should be placed in every package. Packaging materials allow penetration of the sterilization agents and maintain sterility of the processed item after sterilization.
Sterilization Procedures: Heat-tolerant dental instruments usually are sterilized by 1) steam under pressure (autoclaving), 2) dry heat, or 3) unsaturated chemical vapor. All sterilization should be performed by using medical sterilization equipment cleared by FDA. The sterilization times, temperatures, and other operating parameters recommended by the manufacturer of the equipment used, as well as instructions for correct use of containers, wraps, and chemical or biological indicators, should always be followed.
Items to be sterilized should be arranged to permit free circulation of the sterilizing agent (e.g., steam, chemical vapor, or dry heat).
Instrument packs should be allowed to dry inside the sterilizer chamber before removing and handling. Packs should not be touched until they are cool and dry because hot packs act as wicks, absorbing moisture, and hence, bacteria from hands.
d- Storage of Sterile Items
• Protect sterility until ready to use
▫ Store to protect packages from dust, moisture, falling on floor
▫ Transport only covered, dry packages
▫ Handle to protect package integrity
• Rotate sterile items first in, first out
• Store and label for effective recall system
• Expiration date vs. Event-related sterilization
▫ Needs a program flex from L&C