Use of Infection Control Protocol among Dental Setup in Chennai

 

Daniel Silas Samuel¹, S. Pavithra Priyadarshoni²

¹Graduate Student, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences,

Saveetha University, Chennai

²Tutor, Department of Public Health Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai

 

ABSTRACT:

Transmission of infectious agents from patients to dental health care personnel (DHCP) in dental setting is very rare. However, from 2003 to 2015, transmissions in dental settings, including patient-patient transmissions, have been documented. In most cases, investigators failed to link a specific lapse of infection prevention and control with a transmission. However, infection prevention procedures included unsafe injection practices, failure to heat sterilize dental handpieces between patients, and failure to monitor (e.g., conduct spore testing) autoclaves. These reports highlight the need for comprehensive training to improve understanding of underlying principles, recommended practices, their implementation, and the conditions that must be met for disease transmission. All dental settings, regardless of level of care provided, must make infection prevention a priority and should be equipped to observe Standard Precautions and other infection prevention recommendations contained in CDC’s Guidelines for Infection Control in Dental Health-Care Settings. The information presented here is based primarily upon the recommendations from the 2003 guideline and represents infection prevention expectations for safe care in dental settings. It is intended for use by anyone needing information about basic infection prevention measures in dental health care setting but is not a replacement for the more extensive guidelines.The dental environment is associated with significant exposure to various micro-organisms. Infection control is one of the prime elements for a successful dental practice. There are many infectious diseases that can be transmitted during a dental treatment. New diseases with serious consequences a high rate of transmission have evolved in the past. Infection control is directed at prevention to exposure of such infections and to prevent it being transferred from person to person. The universal law for infection control considers that ‘Every patient should be considered Infectious’. This review article represents various aspects of infection control in dental environment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION:

Infection prevention and control is an important part of the safe patient care. Concerns about the possible spread of blood borne diseases and the impact of emerging highly contagious infections, respiratory problems and other illness require practitioners to establish, to evaluate, continually update and monitor the infection control strategies and protocols.

 

Risk Assessment:

The risk of transmission of microorganisms will vary depending on type of dental procedure performed and the likelihood of exposure to blood, body fluids and secretions and non-Intact skin involves the usage of personal protective equipment. Procedures involving no anticipated exposure may require fewer precautions [1]

Medical History:

Thorough medical history of patient should be asked before starting with any dental procedures. It prevents the spread of microorganisms involved in tuberculosis, herpes, etc from infecting the clinical surroundings. [2]

 

Cross Infection:

These are infection transmitted  among patients and from patient to operator within clinical environment Occupational Safety and Health Administration (OSHA) guidelines should be followed to prevent cross infection which includes keeping the working environment clean, hand hygiene, personal protective barriers, instruments disinfection, avoiding instrument accidents, prohibiting eating, drinking, food storage and handling contact lens etc in contaminated environments. [3]

 

Hand Hygiene:

Hand hygiene is the single most important measure of preventing transmission of micro-organisms [4]. Hands should be washed with plain or anti-microbial soap and running water:

1    When hands are visibly soiled (including with water from gloves) or contaminated with body fluids.

2    Following personal body functions.

 

Personal Protective Equipment:

Practitioners wear personal protective equipment to shield themselves from exposure to infectious material. Additional protective barriers and techniques should be employed to shield patients from infectious material. [5]

 

Protective Eye Wear:

Large particles of water, saliva, blood, microorganism and other debris are created by usage of dental handpieces, air/water syringes, the visible spray typically travel a short distance and gets settled out quickly, landing on nearby surfaces, and lands on the patients and the practitioners. Patients should be provided with eyewear to shield eyes from spatter and debris during dental procedures. Protective eyewear should be worn during dental appointment and disinfected after use and whenever becoming visibly contaminated. [6]

 

Protective Draping:

Single use bibs or drapes should be used to protect patients from spatter and debris created during dental procedures, single use strips may be used to secure bibs and drapes in place of reusable daisy chains. [7]

 

Protective Coverings:

Practitioner and their assistants should wear aprons or gowns to prevent spattering or splashing of blood and saliva from contacting skin. The soiled aprons should be changed and cleaned regularly to avoid infection. [8]

 

Foot-Wear:

Dentist and the assistant should wear protective footwear to prevent injury from any sharp objects on floor thereby preventing infection caused by occupational hazard.

 

 

Mouth Masks and Gloves:

Dentists and the assistant should wear mouth mask to prevent infection due to aerosol from aerator and spatter. While treating patient affected by tuberculosis double mouth masks should be worn by the operator. For procedures involving blood, saliva and mucous membrane, gloves must be worn (latex/nitrite) which should be changed for each patient [9].  Damaged gloves should be replaced, and hands must be disinfected before and after using gloves and then dried with disposable paper towels. If there are any cuts or injury in hand of the operator, the injured site must be covered with adhesive waterproof dressing. Head cap should be worn during procedure to protect from spatter or blood splash.

 

Use of Rubber Dam and High-Volume Suction:

Efforts should be made to minimize the spread of droplets, spatter and spray during dental procedures. A rubber dam should be used whenever feasible, and high-volume suction should be used to remove droplets, sprays, is possible. Usage of rubber dam and high-volume suction minimizes the inhalation of contaminated material and debris [10]

 

Handling and Disposal of Sharps:

It must be stressed that extreme care should always be taken to ensure patients are protected from injuries involving sharp objects. Sharp items should be kept out of reach of patients and safely collected in a clearly labelled puncture-resistant container which should be sealed. While handling sharp items, dentists and assistant should be careful and those instruments like scalpel, syringes, etc should be placed in far most corner of the tray, so that it doesn’t harm patient, assistant and operator leading to accidents.

 

Prevention of Infection Contact:

·      Foremost work should be carried out as tidily and orderly as possible.

·      Equipment should be Cleansed by machine instead of hand.

·      Gloves should be worn during the administration of anaesthetic agents.

·      Needles should be bent, broken or otherwise manipulated.

·      Needles should not be guided between the fingers.

·      Used needles should be placed in a needle container after use.

·      The needle containers should meet the clinical protocols for storage [11]

·      For the handling of used equipment gloves should be worn that protect against   pricks and cuts(12)

 

Employee Health:

It is quite handful for a dental practitioner to work without an assistant. Centre for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) suggests practitioners and their assistant should follow infection control protocol to make the dental office a safety and healthy environment for the patient. Immunization with Hepatitis B vaccine, Influenza, measles/mumps/rubella (MMR), tetanus/ diphtheria/pertussis (TDP), Varicella should be administered to the assistants within ten days of their joining to make them protected, thereby protecting patients and clinical surroundings from exposure.

Sterilization and Disinfection:

According to Centres for Disease Control (CDC), dental instruments are classified into three categories depending on the risk of transmitting infection.

 

1) Critical Instruments are those used to penetrate soft tissue or bone, bloodstream or other normal sterile tissue. Sterilization is achieved by steam under pressure, Critical instruments used are forceps, scalpels, bone chisels, scalers and surgical burs.

 

2) Semi-Critical Instruments are that which does not penetrate soft tissues or bone but contact mucous membranes or non-intact skin, such as mirrors, reusable impression trays and amalgam condensers. These devices should be sterilized after each use.

 

3) Non-Critical Instruments are those that meet intact skin such as external components of x-ray heads, blood pressure cuffs and pulse oximeters. These devices have a relatively low risk of transmitting infections compared to other instruments. [13]

 

Sterilization:

Before sterilization it is mandatory instruments should be cleaned, dried, inspected and assembled into functional sets. Hinged instruments are kept open and unlocked.

 

Autoclaves:

·      Also known as steam pressure sterilization.

·      It is of two types namely vacuum and non-vacuum /downward displacement

·      Uses: To sterilize critical and semi-critical instruments

·      Vacuum types are used for any kind of objects including solid instruments, porous objects (drapes or gowns) and hollow objects(dental hand pieces and cannulae), double wrapped packaged and unpackaged instruments.

·      Non-Vacuum types sterilize only unpackaged solid instruments.

·      Working parameter-121 degree Celsius for 20 minutes at a pressure of 15 psi.

 

Hot Air Oven:

·      Most widely used mode of sterilization.

·      Works at a temperature of 170⁰ C for 1-2hours.

·      Uses: Glassware’s like glass syringes, pipettes, test tubes, surgical instruments like scalpel, scissor, forceps, etc.

 

Chemiclave:

·      Operates at 131⁰ and 20 lbs pressure for 30 minutes.

·      Used to sterilize carbon steel instruments and other corrosion sensitive instruments and pliers.

·      It is also known by chemical vapour pressure sterilization.

 

Dry Heat Sterilization:

·      Operates at 188°C-199°C

·      Rapid cycle possible at higher temperatures.

·      Used to sterilize carbon steel instruments and burs.

 

Etox:

·      Abbreviated as Ethylene Oxide Sterilization.[14]

·      Used to sterilize complex instruments like hand pieces and delicate materials.

·      It operates at low temperature.

·      Disadvantage is Potentially mutagenic and carcinogenic.

 

Disinfection:

Maintaining the clinical environment infection free is mandatory. Certain disinfectants and barriers are used for the very purpose.

 

Classification:

High Level Disinfection:

Inactivates vegetative bacteria, mycobacteria, fungi, viruses and bacterial spores. Includes glutaraldehyde, hydrogen peroxide, peracetic acid and chlorines.

 

Intermediate Level Disinfection:

Inactivates vegetative bacteria, majority of fungi, mycobacterium, enveloped viruses but not bacterial spores. Includes alcohol, iodophors, phenolics and chlorines. [19]

 

Low Level Disinfection:

Inactivates majority of vegetative bacteria, certain fungi and viruses but not mycobacteria and spores. Includes alcohol, iodophors, phenolics and chlorines.

 

Dental Water Units:

The water line connecting dental units like ultrasonic scalers, aerator, 3-way syringe, suctions, etc should be checked for infection on a regular basis. Instead of public water, self-contained water units combined with bottled water can be used for dental units, hand washing or for mixing disinfectants.

 

Surface Covering:

Surfaces which can’t be sterilized or disinfected should be covered with appropriate materials like special rollers, plasticized paper, sheets, cellulose film, aluminium foil, self-adhesive films, nylon cases, latex and vinyl cases. These are used as barriers and should be replaced after every patient contact.

 

Radiological Asepsis:

While taking intro-oral radiographs there is an increased risk for cross infection. Certain precautions should be followed to avoid that:

Ÿ  Gloves must be worn for every patient.

Ÿ  All film holders must be washed and sterilized after use.

Ÿ  Low or intermediate level disinfectants are used to clean X-ray tube head and control panel in case of contamination. [15]

Ÿ  Digital radiography sensors and imaging plated should be disinfected after each patient or must be barrier protected.

 

Laboratory Items:

These include impressions and appliances which should be rinsed thoroughly in water and then immersed in disinfectants like 2% glutaraldehyde or 0.1% sodium hypochlorite before further processing. (16)

 

Biopsy Specimens:

Biopsy specimens collected for transportation should be kept in sturdy containers with secure lid as it is the main source of infection. Swab specimen collected should be transferred to swab container slowly and carefully.

 

Disinfectants:

The following disinfectants can be used in dental practice

 

1) Alcohol:

Alcohol is used for disinfecting skin and hands, Hand hygiene70% alcohol without any additives is used for disinfecting small surfaces and objects. Commonly used disinfectants in dis-infect ants are isopropyl alcohol and 70%ethyl alcohol. (17)

 

Duration:

Wet the surface well and leave it to dry in the air, in the case of immersion leave for 10minutes.

2) Chlorine Preparation:

250 ppm of chlorine can be used for surface disinfection from micro-organisms. For surfaces that have been contaminated with blood or other bodily fluids a 1,000 ppm of chlorine solution is used (250 ppm = 0.025% and 1,000 ppm = 0.1% of free chlorine).

 

Duration:

Wet the surfaces well and leave it to dry in the air.

 

3) Peroxides:

Hydrogen peroxide, peracetic acid and sodium perborate are used for disinfection purposes. Peracetic acid is permitted as an instrument disinfectant and sodium perborate as a disinfecting storage fluid in case cleaning is delayed for some time. Peroxides are corrosive for a lot of materials including non-elixated aluminium, brass, rubber and textile. (18)

 

4) Aldehydes:

Formaldehyde acts as bactericidal and sporicidal agent and is active against gram negative bacteria, spores, viruses like HB, HIV and fungi. (19)

 

5) Phenols:

Surface disinfectants like cresol (lysol), chlorhexidine (savlon), chloroxylenol (dettol) are used to maintain the clinical surface clean. Phenols are low efficiency disinfectants, so it is mostly not suitable for cleaning surgical instruments.[20]

 

6) Iodophores and Iodines:

These are active against bacteria, spores, some viruses and fungi and are suitable for skin preparation, mouthwash and as surgical scrub. (21)

 

CONCLUSION:

“Prevention is better than Cure” is an old saying which is often quoted but seldom followed. But in the light of recent increase in infections in hospitals and dental clinics, it is vital that the necessary steps are taken to prevent such incidents for the welfare and wellbeing of both the patients and the Doctors.

 

REFERENCE:

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2.     Pottinger J, Burns’ S, Manske C. Bacterial carriage by artificial versus natural nails. Am J Infect Control 1989; 17:340-344.

3.     Hoffman PN, Cooke EM, McCarville MR, Emmerson AM. Micro-organisms isolated from skin under wedding rings worn by hospital staff. Br Med J 1985; 290:206-207.

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7.     Gezondheidsraad. Commissie Vaccinatie tegen hepatitis B. Bescherming tegen hepatitis B. 1996; 15.

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9.     Larson E. A causal link between handwashing and risk of infection? Examination of the evidence. Inf Control Hosp Epidemy 1988; 9(1):28-36.

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11.   CBO. Consensus preventie ziekenhuisinfecties. 1989.

12.   Kampf G, Kramer A. Epidemiologic Background of Hand Hygiene and Evaluation of the Most Important Agents for Scrubs and Rubs. Clinical Microbiology Reviews 2004; 17(4):863-893.

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14.   Pitten FA, Herdemann G, Kramer A. The Integrity of Latex Gloves in Clinical Dental Practice. Infection 2000; 28(6):388-392.

15.   L.C.I. Landelijkerichtlijn Prikaccidenten. 2007.

16.   Gwyther J. Sharps disposal containers and their use. J Hosp Infect 1990; 15:287- 294.

17.   De Bruijn ACP, van Drongelen AW, Wassenaar C. De Europese norm voor kleine steam steriliseren. Tijdschr Hyg en Inf Prev 2000; 5:125-130.Infection prevention in dental practice 21

18.   R. Varshan, Meignana Arumugham, Ashish R. Jain. Knowledge and practice of infection control among dental students, Saveetha University, Tamil Nadu. Journal of Pharmacy Research 11(12) 2017:1499-1502

19.   Santhosh Kumar MP, Saveetha University, Tamil Nadu. Knowledge, attitude and practices regarding infection control. Asian Journal of Pharmaceutical and clinical research 9:1(2016):220-224

20.   Velmurugan Rajan and Mohammad Nabeel Nazar, Saveetha University, Tamil Nadu. Research Journal of Pharmaceutical, biological and chemical sciences. Cross infection control in Dentistry (2014) 5(2):650-657

21.   Harrita S, Dhanraj and Preetham Prasad, Saveetha University, Tamil Nadu, International Journal of Advanced Research(2017)

 

 

 

 

 

 

 

 

Received on 12.11.2018          Modified on 25.12.2018

Accepted on 23.01.2019        © RJPT All right reserved