INFECTION CONTROL IN FIXED PROSTHODONTICS

Prepared & Presented By:

LAYOUT

OBJECTIVES

Protect one self, staff and patients Use of protective gear and proper sterilization to minimize infection risks Ensuring the patient the highest standard of care Providing a relaxed and non-threatening environment to minimize patients anxiety.

OBJECTIVES

To fulfill these objectives, a basic understanding of microbiology is essential.

There are 3 types of microorganisms:
Pathogenic Potentially pathogenic Non-pathogenic

Opportunistic infections occur in those whose immune systems are compromised (eg. Oral Candidiasis: fungi)

MODES OF TRANSMISSION
Direct: person to person Indirect: contact with objects that are contaminated Air-borne: spray or splatter contact with mucous membranes, or contact with aerosols
A high speed handpiece is capable of creating air-borne: Bacteria: from water-spray system Microbial contaminants: from saliva, tissues, blood, plaque and debris from cutting carious teeth These exist in the form of spatter, mists and aerosols.

MODES OF TRANSMISSION
Aerosols (50mm-55mm) may carry agents of respiratory infection, borne by the patient (airborne or blood-borne). Mists (50mm) are likely to transmit active pulmonary/pharyngeal tuberculosis from the cough of a patient. Spatter has a trajectory of 3 ft from the patients mouth. It is a potential route of blood-borne pathogens.

PREVENTION
PRETREATMENT
Hand washing Mouth rinse Rubber dam High-velocity air evacuation

DURING TREATMENT
Gloves Gowns Masks Protective eyewear Adequate air circulation

VIRAL HEPATITIS
A
Source of virus
feces

D
blood/ blood-derived body fluids

E
feces

blood/ blood/ blood-derived blood-derived body fluids body fluids

Route of transmission
Chronic infection Prevention

fecal-oral

percutaneous permucosal
yes

percutaneous permucosal
yes

percutaneous permucosal
yes

fecal-oral

no

no

preexposure immunization

pre/postexposure immunization

blood donor pre/postscreening; exposure risk behavior immunization; modification risk behavior modification

ensure safe drinking water

HBV CONCENTRATION IN BODY FLUIDS Urine

Semen HIGH Blood Serum Wound Exudates Vaginal Fluid Saliva

LOW
Feces Sweat

Tears
Moderate

Breast milk

HIV RISK FOR DENTAL PERSONNEL

Precautions must be made to minimize injury by needles or sharp instruments used to treat HIV infected patients. Patients seriously ill with AIDS may harbor transmissible respiratory infections such as tuberculosis and CMV infections. Personnel without adequate barrier protection should avoid exposure to coughing , saliva spatter and heavy aerosol from HIV infected person with signs of respiratory infections. Pregnant women should especially be cautious of transmitting CMV infection to new-born USING INFECTION CONTROL MEASURES , THE RISK FOR INFECTION TRANSFER IS VERY LOW.

 HIV is killed by all methods of sterilization. When used properly, all disinfectants except some quaternary ammonium compounds, are said to inactivate HIV in less than 2 minutes. In dried infected blood, 99% of HIV has been found to be inactive in appx. 90 minutes. However when kept wet, the virus may survive for 2 or more days. Hence caution is required with container of used needles in which the virus may remain wet.

HIV INFECTION CONTROL

Barriers have proved successful in protecting dental personnel. HIV has been found to mostly be transmitted by blood contaminated fluids that have been heavily spattered or splashed.

CRITICAL ITEMS

Instruments that cut or penetrate through tissues Require thorough cleaning and sterilization

SEMI-CRITICAL ITEMS
Items handled by gloved hands coated with blood and saliva or may touch mucosa.
Air-water syringe tip Suction tip Handpieces Lamp handles

Must be removed to clean and sterilize unless disposable or can be protected using plastic covers.

NON-CRITICAL ITEMS
Items not ordinarily touched during treatment. Environmental surfaces:
Chairs Floor/walls Supporting equipment of dental unit

Contaminated items require cleaning and disinfection. Wear gloves to clean. Uncovered chair arms may become contaminated with spatter.

ASEPTIC TECHNIQUES
Prevents cross-contamination. All items touched with saliva MUST be free of contamination before treating next patient. Contaminated items can be:
Discarded/Removed Protected by disposable covers Cleaned Sterilized

Clinician should NOT directly touch items that he/she does not want to contaminate

BETWEEN PATIENT APPOINTMENTS

Whatever is touched is contaminated.

Directly touch ONLY what has to be touched.

BETWEEN PATIENT APPOINTMENTS

Use one of the following to control contamination:
a) Clean and sterilize b) Protect surfaces and equipments, that are not sterilized, with disposable, single-covers. Discard after every appointment. c) Use paper towel/plastic bags over gloves to handle equipments briefly (cabinets/drawers) d) Scrub and disinfect noncritical surfaces (countertops, door handles, light switches etc.)

DISINFECTANTS
Regarding disinfection, these two principles should be remembered:
1. Disinfection cannot occur until fresh disinfectant is reapplied to a thoroughly cleaned surface. 2. Disinfection does not sterilize.

DISINFECTANTS
MUST be active against:
Mycobacterium species Polioviruses Staphylococcus species Pseudomonas species HIV (within 1-2 mins)

Activity is reduced by organic debris/blood.

Most water-based disinfectants are effective for removing dried blood.

DISINFECTANTS
Major categories of chemical disinfectants:
1. 2. 3. 4. 5. Chlorine compounds Iodophors Combination synthetic phenolics Glutaraldehydes Phenolic/alcohol combinations

These can be used using different methods of disinfection like spraying and immersion techniques.

DISINFECTANTS

Some drawbacks of chemical disinfectants:

Not readily compatible with irreversible hydrocolloids Potentially harmful to users health and environment May have unpleasant odor Take time Expensive

DISINFECTANTS

Factors influencing disinfectants effectiveness:

1) Type of micro-organism 2) Number of micro-organism 3) Concentration of disinfectant 4) Length of exposure time of disinfectant 5) Amount of organic matter [bio-burden] remaining

DISINFECTANTS
70-79% ethyl alcohol
MOST effective on cleaned surfaces

Chlorine and iodine:

React and absorbed by plastic of dispensing bottles.

Glutaraldehydes (conc.)
Used for instrument disinfection Highly toxic 20 min.s to kill mycobacterium species

PERSONNEL HEALTH ELEMENTS

Education and training Immunizations Exposure prevention and post-exposure management Medical condition management and workrelated illnesses and restrictions Health record maintenance

PERSONNEL BARRIER PROTECTION

Hand washing Gloves Eyewear Masks Hair protection Protective over-garment

HAND WASHING
Hands must be washed when: Visibly dirty After touching contaminated objects with bare hands Before and after patient treatment (before glove placement and after glove removal)
GOOD BETTER BEST

Plain Soap

Anti-microbial Soap

Alcohol-based Soap

http://www.cdc.gov/handhygiene/materials.htm

HAND WASHING
Hand cleansers containing a mild antiseptic such as:
1. 3% parachlorometaxylenol (PCMX) or Chlorhexidine:
Preferred to control transient pathogens Suppress overgrowth of skin bacteria.

2. Hand cleansers with 4% chlorhexidine:

Special cleansing (e.g. for surgery gloves leak or clinician experiences injury) Can be hazardous to eyes.

3. Alcohol rubs:
Effective against pathogens Less drying to the hands

ALCOHOL-BASED SOAP
Limitations Benefits
Rapid and effective antimicrobial action Improved skin condition More accessible than sinks Cannot be used if hands are visibly soiled Store away from high temperatures or flames Hand softeners and glove powders may build-up

SPECIAL HAND HYGIENE

Keep fingernails short Avoid artificial nails Avoid hand jewellery that may tear gloves Use hand lotions to prevent skin dryness
Consider compatibility of hand care products with gloves (e.g., mineral oils and petroleum bases may cause early glove failure)

GLOVES
OSHA regulations specifies that all clinical personnel MUST wear treatment gloves during all treatment procedures and each appointment. Gloves must meet new FDA regulations . Puncture-resistant utility gloves should be worn. If a leak is detected, gloves are removed, hands are washed, and fresh gloves are used on DRY hands.

GLOVES

Gloves must NOT be washed

Must NOT be used for more than one patient. Gloves help prevent painful and transmissible herpetic infections to fingers (WHITLOW) and hands.

REMOVAL OF GLOVES
Pinch the palm side of the outer cuff surface with the gloved fingers of the other hand.

Pull off the glove, inverting it.

Remove both gloves simultaneously in the same manner.
Alternately, after removing one, insert bare fingers under the cuff to grasp and pull off the remaining glove.

Discard gloves safely.

EYE WEAR
May consist of goggles or glasses with solid sideshields.

Should be worn with clean hands before gloving and removed with clean hands after gloves are removed.

MASK
Should be worn to protect against aerosols. Edges of the rectangular mask should be pressed close around the bridge of the nose and face. Face Shields are also used for heavy spatter.

HAIR PROTECTION
Hair should be kept back, out of the treatment field, because hair can entrap heavy contamination. Personnel should protect their hair with a surgical cap when encountering heavy spatter (e.g. from an ultrasonic scaling device).

OVER-GARMENT
An over-garment must be protective of clothing and Sleeves with knit cuffs that tuck skin
under gloves are preferred. Simple light-weight garment Must cover the arms and chest up to the neck and the lap when seated, provide more adequate protection. Garments should be changed and skin be washed as soon as possible in case of treatments that produce spatter that wets or penetrates the garment.

OVER-GARMENT

Wear gowns, lab coats, or uniforms that cover skin and personal clothing likely to become soiled with blood, saliva, or infectious material Change if visibly soiled Remove all barriers before leaving the work area

DISPOSAL OF CLINICAL WASTE

Contaminated materials such as blood-soaked or saliva-soaked sponges, and cotton rolls must be discarded safely. Excised tissue require separate disposal and may not be discarded into the trash.

NEEDLE DISPOSAL
Goals for needle disposal are:
Dispose off needles in a hardwalled, leak-proof, and sealable container which has the OSHA biohazard label. Locate the needle-disposal container in the operatory close to where the needle will be used Avoid carrying unsheathed contaminated needles or containers in a manner that could endanger others.

PRECAUTIONS TO AVOID INJURY

The same principles that apply to needles should be reasonably translated and applied, however to used burs, wires, and sharp instruments from the operatory.

Great care should be used in passing instruments and syringes with unsheathed needles to another individual.

PRECAUTIONS TO AVOID INJURY

Sharp and curved ends should be turned away from the recipients hand. Burs should be removed from handpieces when finished or if left in the handpiece in the hanger, the bur should be pointed away from the hands and body.

Hanging handpieces upside down in some types of hangers can angle the bur away from the operator.

HANDPIECE SURFACE CONTAMINATION CONTROL

Blood and saliva contaminate the surfaces of handpieces during various dental treatments.
Irregular surfaces and especially crevices around the bur chuck are difficult to clean and disinfect, especially by a brief wipe with a disinfectant-soaked sponge.

Submersion of a high-speed handpiece in a high-level disinfectant has not been an option accepted by manufacturers.

Only STERILIZATION can approach complete infection control of handpiece surfaces.

INSTRUMENT PROCESSING AREA

Use a designated processing area to control quality and ensure safety. To prevent crosscontamination, the instrument processing area should be physically or spatially divided into regions for:
Receiving, cleaning, and decontamination Preparation and packaging Sterilization Storage

DISINFECTION OF IMPRESSIONS & PREOSTHESES

All prosthesis removed from the mouth should be carefully rinsed under running water, cleaned of debris in an ultra-sonic cleaner whenever possible, and disinfected. All impressions should be rinsed and disinfected before the dental stone models are fabricated. Working pumice should be discarded after use Lathe attachments such as stones, acrylic burs, and rag wheels, should be removed from the lathe after each use and stored in a disinfectant.

DISINFECTION OF IMPRESSIONS & PREOSTHESES

Lathe shields and air filtrations should be used to contain contaminated splashes and airborne contamination. Care should be exercised to clean and disinfect touch and splash surfaces in the laboratory. Clothing worn during patient treatment should be covered with a disposable apron, specially when contaminated impressions and prosthesis are handled.

DISINFECTION OF IMPRESSIONS & PREOSTHESES

Impressions can also be disinfected and sterilized using ultraviolet radiation and gas [ethylene dioxide] in closed chambers.
A cast from a properly disinfected impression may subsequently become contaminated by a technician and/or a clinician. Also the prosthesis will become contaminated by patient after try in; this can re-contaminate the cast after repositioning. In practice, it is thus, difficult to chemically disinfect the contaminated gypsum casts.

MICROWAVE IRRADIATION
Studies have been carried out to disinfect contaminated gypsum casts through microwave irradiation. Unlike impression disinfection, this method can be used to eliminate cross-contamination via the cast, as it can be repeated at every stage as required.

So far it has been observed that microwave irradiation of the casts for 5 minutes at 900W gives high level disinfection of the gypsum casts.

STERILIZATION
Autoclave sterilization of handpieces One of the most rapid methods. Works at 121*C for 20 min and 15 lb pressure. All stainless steel instruments & burs can be autoclaved. Chemical vapor pressure sterilization Recommended for some types of handpieces Works at 131*C for 30 min and at 20lb pressure by using aldehyde vapours. Carbon steel and other corrosion sensitive burs can be sterilized.

SUMMARY
All dental disciplines must be considered with the dangers involved in the spread of certain infectious diseases.

Prosthodontists and their personnel may be exposed to certain diseases such as Hepatitis and Tuberculosis.
Dentists must ensure that they at least follow the basic infection control procedures.

Additional infection control procedures should be observed in the fabrication and handling of dental impressions and prosthesis.
Dental offices and labs should work closely together to coordinate control of potential cross-infections between the two disciplines.