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Infection Control

Module 2
Disease Transmission
Nancy Goodwin, CDA, RDH, MEd.
All rights reserved

Some things to consider.

How many of our patients may have a


disease that we could catch that they
dont know that they have?
Do you think that everyone who has a
condition like Hepatitis or AIDS discloses
that to us?
Does that thought affect how you prepare
your operatory?
Does it affect whether or not you wear your
personal protective equipment like mask,
gloves and glasses?

Objectives

After completing this module, the participant will be able to:

List the viral diseases that are a concern to dental personnel


including Hepatitis A, B, C, D, and E, HIV, the Herpes Simplex
viruses, and SARS.
Discuss the modes of transmission for the viral diseases listed.
List the bacterial diseases that are a concern to dental personnel
including Tuberculosis, Legionnaires disease, Tetanus, Syphilis and
Gonorrhea.
Discuss the modes of transmission for the bacterial diseases listed.

Discuss the methods for preventing transmission of the viral and


bacterial diseases listed as it relates to the chain of infection.
Name the disease that is considered the greatest threat to a
dental professional.
Discuss the difference between virulence and fragility in relationship
to potential pathogens.

To review..

Disease transmission in the dental office can


occur
From the patient to the dental
worker
From the dental worker to the
patient
From one patient to another
From the dental office to the
community

Transmission can be

Direct- from an infected person to another


person who is not immune,

Indirect- from contact with objects that are


contaminated, like surfaces or instruments,

Droplet-from spray or splatter contact with


mucous membranes, or airborne(from aerosols
which are suspended in the air and inadvertently
inhaled).

These pathogens can travel from their


reservoir through blood (Blood-borne) or
through the air (airborne), directly or
indirectly.

Each pathogen has a specific way in which


it is transmitted.

Next, we will list the pathogens which can


be transmitted in a dental office in detail.

Hepatitis Viruses

Viral Hepatitis

Five types of Hepatitis cause diseases that look


similar clinically: Hepatitis A, B, C, D, and E.

Hepatitis A and E are transmitted primarily


through contaminated food or water, or through
the fecal-oral route.

Hepatitis B, C and D are bloodborne diseases


usually transmitted through direct or indirect
contact with infected body fluids.

Bloodborne diseases are one of the main


concerns for dental healthcare workers.

Hepatitis B(HBV)

Is a major health problem in the U.S.


The CDC estimates that there are
somewhere between 1 and 1.25 million
carriers of hepatitis B in the U. S.
Approximately 10% of people who have
had Hepatitis B become carriers.
These carriers have the potential to spread
the disease to others.

Hepatitis B (continued)

Some carriers had the disease subclinically, that


is, without definitive symptoms, and may be
unaware that they are carriers.

Saliva is one of the body fluids found to transmit


many bloodborne pathogens.

A milliliter of blood from an infected person


may contain as many as 100 million virus
particles, meaning that only small amounts of
blood or other body fluids are necessary to
transmit the disease to others.
(Miller & Palenik, 2005, p. 75)

Hepatitis B (continued)

The most transmissible blood-borne disease is


not HIV, but the Hepatitis B virus.

Healthcare workers can be exposed to the virus


in an infected persons blood through a stick
with a sharp instrument or needle, or through
spatter contacting their eyes, nose or mouth.

Any cuts, cracks or scrapes of the skin should be


covered because they also a potential portal of
entry.

Hepatitis B (continued)

Since no treatment exists to cure this


disease, prevention is critical.

For this reason, OSHA recommends that


all members of the dental team receive the
Hepatitis B vaccine. (We will discuss this
more in Module 3).

Hepatitis B can survive outside


the body for at least seven days
and still be capable of
transmitting infection.
269

Bird & Robinson, 2005, p.

Hepatitis B
Transmission of Hepatitis B can
occur:
Parenterally (Percutaneous) =stick
through the skin
Permucosally =through mucosal tissues
Through sexual contact
Prenatally= mother to child
Other= unknown source

Hepatitis B
The greatest risks to the dental healthcare
worker occur from:
Injuries from contaminated sharps
Blood and saliva contamination of cuts
and cracks on the skin; ungloved hands;
gloves that became torn
Spray and splatter onto open lesions on
skin or into mucous membranes (eyes,
nose, mouth)

Application to practice

How could you prevent risks from


contaminated sharps in your practice?
How could you prevent exposure from
spray or splatter during patient care?
How can you avoid exposure on non-intact
skin?

Hepatitis C (HCV)

Blood-borne disease
An emerging disease (increasing)
Transmission is the same as Hepatitis B
About 25,000 persons in the U.S. are
estimated to become infected with HCV
every year, but only 20% of those infected
have any (generally mild) recognizable
symptoms
Miller & Palenik, 2005, p. 81

Hepatitis C

Hepatitis C has been transmitted to health


care workers through needlestick injuries.

In some cases of Hepatitis C, the virus has


remained latent (no symptoms) for as
many as 20 years. This fact makes
Hepatitis C a significant concern for dental
workers because patients may not know
that they are infected.

There is no vaccine for Hepatitis C.

Application to practice

Spend a few minutes considering how


many of our patients may have a condition
such as Hepatitis C which is undiagnosed.
After you have seen this information, does
it affect how you prepare your operatory?
How about whether or not you wear your
personal protective equipment like mask,
gloves and glasses?

Hepatitis D (HDV)

Known as Delta virus


May only cause infection in the presence of
Hepatitis B (piggy back virus)
Bloodborne virus
Transmission by the same routes as HBV
and HCV
Vaccination against HBV will protect
against HDV.

Link to Hepatitis Article

The ABCs of Hepatitis:

http://www.osap.org/associations/4930/fi
les/Feb%20ICIP%20final.pdf
On this link,
find one fact that you
didnt know about Hepatitis.

Human
Immunodeficiency Virus

Human Immunodeficiency Virus


(HIV)

Bloodborne viral disease


Disease that breaks down the bodys
immune system
Acquired Immunodeficiency syndrome
(AIDS) is caused by HIV infection.
CDC estimates more than 1.25 million
people in the U.S. are infected; 42 million
worldwide.

Human Immunodeficiency Virus


(continued)

In the U.S., time from the initial phase


(HIV infection) to the terminal phase of
the disease (AIDS) has increased because
of the use and availability of antiviral
drugs.
Life expectancy after infection, with the
help of the antiviral medicines, is around
25 years in most infected individuals.

Human Immunodeficiency Virus


(continued)

Transmission is primarily through:

Intimate sexual contact

Exposure to blood, blood-contaminated


body fluids

Perinatal contact (mother to child)

HIV (Continued)

Many infected persons are unaware of


their HIV status if they have not been
tested.
The risk of HIV transmission from a
patient to a dental healthcare worker is
low.
The HIV virus is considered fragile in
that it cannot survive on surfaces like HBV
(which is considered virulent).

Link
Managing the care of patients with a
bloodborne illness (read abstract only)
http://jada.ada.org/cgi/content/abstr
act/134/3/350?maxtoshow=&HITS=10&hits
=10&RESULTFORMAT=1&author1=
DePaola&andorexacttitle=
and&andorexacttitleabs=
and&andorexactfulltext=and&searchid
=1&FIRSTINDEX=0&sortspec=
relevance&resourcetype=HWCIT

Herpesviruses

Herpes viruses

Herpes viruses cause numerous infections in


humans including herpes simplex,
cytomegalovirus, chickenpox, shingles,
mononucleosis, roseola.
Transmission occurs from direct contact with
the lesions or from contact with the saliva of
infected individuals.
The virus can enter through non-intact skin on
the hands leading to vesicle development on the
fingers. ( Herpetic Whitlow)
http://dermnetnz.org/viral/herpes-simplex.html

Patients with active oral lesions should be


reappointed until lesions subside.

Avoid direct contact with the lesion since


the related vesicles contain active virus.
These types of lesions are also contagious
immediately before the outbreak.

http://dermnetnz.org/viral/herpes-simplex.html

Herpesviruses

These types of viruses become dormant


after the initial infection and may become
activated later to cause disease

Although there are drug therapies


available to control symptoms, there is no
cure. A new vaccination is available to
protect only against specific types of
genital herpes.

Herpes Simplex Virus


Is divided into 2 types:
1.
Herpes Simplex Type 1 (HSV1)primarily causes oral lesions
2.
Herpes Simplex Type 2 (HSV2)primarily causes genital lesions and is
one of the most common STDs.
**the possibility exists for Type 2 lesions to
be seen orally

Herpes simplex

After the initial outbreak, the herpes


simplex virus travels up the nerve of the
involved area to reside in the ganglion
where it remains dormant for a time.

The virus can become active again and


travel back down the nerve, causing
another outbreak.

Application to practice

How can you best protect yourself from an


occupational exposure to the Herpes
virus?

**reschedule the patient with an active lesion. This will


protect you and your patient.

Herpes Zoster Virus


(Human Herpesvirus Type 3)

Also known as HZV


Causes both varicella (chickenpox) and
herpes zoster (shingles)
In this case, varicella is the initial
infection, and herpes zoster is the
reactivation of the latent virus.
It is highly contagious to an individual
who has not been exposed to the virus.

Chicken
pox
Varicella

Shingles
Zoster

Herpes Zoster Virus


(Human Herpesvirus Type 3)

The virus enters the body through droplet


infection, invades the respiratory tract,
and is spread via the bloodstream to the
skin and other parts of the body.

It is spread through saliva and nasal


secretions as well as direct contact with
the lesions.

Herpes Zoster Virus


(Human Herpesvirus Type 3)

The FDA approved a vaccination in


1996

This vaccine is recommended for


dental healthcare personnel who
never had chicken pox or cannot
confirm immunity with a blood test.

Epstein-Barr Virus
(Human Herpesvirus type 4)

This virus causes infectious mononucleosis


in adolescents and young adults.

Transmission is a result of direct contact


with an infected persons saliva, or
occasionally from a blood transfusion.

There is no vaccine.

Cytomegalovirus
(Human Herpesvirus Type 5)

Does not usually cause symptoms at the


point of primary infection, but can cause
disease in the infants and
immunocompromised individuals.

Transmission is through direct contact


with secretions, including saliva.

Human Herpesviruses Types 6,7,8

Types 6 and 7 have been isolated from


saliva.
Type 6 causes Roseola
Type 7 has not been associated with any
particular disease.
Kaposis Sarcoma, which is a common
infection in AIDS patients, has been linked
to Type 8.

Severe Acute Respiratory


Syndrome (SARS)

Viral respiratory illness


The virus is transmitted through
respiratory droplets that are spread when
an infected person coughs or sneezes.
Extremely rare in the U.S.
Only a concern when a patient has
traveled to an area where the virus is
common.

Bacterial Infections

Tuberculosis

Caused by the bacteria, Mycobacterium


Tuberculosis

Dental offices are not equipped to treat


patients with active tuberculosis. Urgent
care must be provided in a hospital
setting.

Tuberculosis

Transmission is by the airborne route; the


disease is acquired by breathing in
respiratory droplets from an infected
individual.
Because these bacteria are so resistant and
difficult to kill, the ability to kill
tuberculosis (tuberculocidal activity) is the
benchmark for surface disinfectants.

All dental personnel should


have a tuberculin skin test
yearly as recommended by
the CDC.

Legionnaires Disease

Caused by the Legionella pneumophila


bacterium.
Transmission is through aerosolization
and aspiration of contaminated water.
No person to person transmission
It has been found in water-handling
systems, including dental unit waterlines.

Legionnaires Disease

Approximately 10% of dental offices have


Legionella in the dental unit water that is used
during patient care.

This means that some dental professionals and


(and patients) may be exposed to Legionella
from the aerosols that are produced by air/water
syringes, ultrasonics, or handpieces.

The risk to dental personnel and to


patients can be minimized by following the
CDC and ADA recommendations
regarding dental unit waterlines.

These guidelines will be discussed in


Module 7.

Tetanus

The causative organism is a spore-forming


bacillus found in soil, dust, or feces that is
constantly present in the environment.
Tetanus vaccinations are recommended
for all children (3 part series: DTP)
followed by boosters every 10 years.
All healthcare personnel should continue
routine tetanus boosters throughout life.

Syphilis

Syphilis is a sexually transmitted disease


caused by Treponema pallidum
spirochetes.
In 5 to 10% of cases, an oral lesion is the
first symptom (chancre)
The lesion contains live spirochetes, which
can be spread by direct contact to
unprotected hands.

Chancre of Syphilis

http://www.cdc.gov/std/training/picturecards/Oral-chancre-upper-lip.pdf

Gonorrhea

Gonorrhea is a sexually transmitted


disease caused by Neisseria gonorrhoeae.
If the bacterium has spread to the mouth
through sexual contact, it may be present
orally may cause an inflammation of the
throat, or oral ulcers.
There is a potential for transmission
through aerosol production in the dental
setting.

Link
Guidelines for Infection Control in Dental
Health-Care Settings --- 2003
(Read Summary, Introduction and
Background onlymore if you like!)

http://www.cdc.gov/mmwr/preview/mmwrh
tml/rr5217a1.htm

For review.

Which pathogens
have bloodborne
transmission?

Which pathogens
have airborne
transmission?

Hepatitis B,C,D
HIV

Tuberculosis
Legionnaires
Gonorrhea (aerosols)

Which pathogens are transmitted through direct

contact with lesions or saliva?


Herpes viruses, Gonorrhea, Syphilis

Now that we have reviewed the


basics of microbiology, the
pathogens that we may encounter
in dentistry, and specific modes of
transmission, we can begin to
discuss protecting ourselves and
our patients from exposure in
Module 3.

References

Bird & Robinson, (2005). Modern Dental Assisting, 8 th Edition. St.


Louis, MO. Elsevier/Saunders.

From Policy to Practice: OSAPs Guide to the Guidelines


(2004).Annapolis, MD. OSAP.

Miller & Palenik, (2005). Infection Control & Management of


Hazardous Materials for the Dental Team. St Louis,MO. OSAP,
Elsevier/Mosby.

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