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.
It
includes:
•
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 |
||
Categories |
Definition |
Dental Instrument or item |
|
Critical |
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. |
|
Semi-critical |
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. |
|
Noncritical |
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
-
Sterilization
-
Storage
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.
c- 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