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Dental Innovative Devices &Educational Solutions LLC Introduction to Dental Infection Control by Dr. Raghunath Puttaiah Principal Partner Dental Innovative Devices & Educational Solutions Plano, Texas, USA Introduction & Rationale • Infectious diseases have changed the course of history “Between smallpox and Spaniards, 3/4ths of the Inca were wiped out within 70 years.” [National Geographic] Pizzaro1 1. "Francisco Pizarro." Wikipedia, The Free Encyclopedia. 9 Sep 2006, 22:12 UTC. Wikimedia Foundation, Inc. "Siege of Tenochtitlan." Wikipedia, The Free Encyclopedia. 8 Sep 2006, 15:56 UTC. Wikimedia Foundation, Inc. Pioneers in Infection Control Wikipedia Wikimedia Wikimedia Ignaz Semmelweiss •Childbed fever caused by Physicians & Medical Students •Washing hands reduced rates from 18% to <2% •Findings not accepted by peers Joseph Lister •Using Carbolic Acid reduced nosocomial infections in the Glasgow General Hospital •Findings well accepted Sushrutha •Considered the father of surgery •400-800BC •Wrote a Treatise on Surgery •Used Fumigation Techniques •Cleaned surgical site with medicinal extracts, flamed instruments Basic Concepts in Infection Control Dental Clinic Bacterial aerosols and fomites P A T I E NT Family & Friends Dentist & Clinic Staff Other Patients Possible spread of a disease cluster Family & Friends Basic Concepts in Infection Control Dental Clinic Bacterial aerosols and fomites #3 P A T I E NT #6 Family & Friends #5 # 4 #3 Dentist & Clinic Staff # 2 Other Patients Possible areas of control to reduce risk of disease #1 Family & Friends Routes of Transmission 1. Percutaneous high Microbes in Blood/Saliva – 2. needle, sharp instruments Contact high Microbes in Blood/Saliva – 3. splash/spatter of blood & body fluids Inhalation moderate 1 2 Suspended Microbes – 4. droplet nuclei and aerosols Indirect contact low Microbes on Surfaces – Fomites/touching contaminated 3 surfaces 4 Infectious Conditions among unprotected and non-immunized DHCWs, & Restriction of Clinical Duties Condition Conjuctivitis Staph. Active Strep. A Viral respiratory TB (active) TB (+ve PPD) Restr. Yes Yes Yes Yes Yes No Influenza Yes Headlouse.org Duration Until discharge ceases Until lesions have healed Until 24 hours after starting TX Until acute symptoms resolve Until treated non-infectious Evaluate for infectious status and care as needed) Until DHCW is asymptomatic Infectious Conditions among unprotected and non-immunized DHCWs, & Restriction of Clinical Duties Condition Pediculosis (Lice) Herpetic whitlow Herpes - Orofacial Restr. Yes Yes Yes Varicella (Ch. Pox) Shingles (Zoster) Hep-B (HBe antigen) Yes Yes Yes Hepatitis C No HIV Yes Duration Until treated and is with no lice Until lesions heal Until clinical lesions are healed (need to be on regular anti-viral meds) Until lesions dry and crust Until lesions dry and crust Until Hepatitis-B e antigen is negative (UP, expert panel and care) UP/SP, Aseptic techniques and care to reduce viral load Expert panel, UP/SP, antiviral meds Infectious Conditions among unprotected and nonimmunized DHCWs, & Restriction of Clinical Duties Condition Measles Mumps Rubella Pertussis Restr. Yes Yes Yes Yes Duration Until 7 days after rash appears Until 9 days after start of parotitis Until 5 days after rash appears Until 5 days after start of effective antibiotic therapy Diarrhea Enteroviral Hepatitis A Yes Yes Yes Until symptoms resolve Until symptoms resolve Until 7 days from onset of Jaundice Standard Precautions/ Universal Precautions Definition: – to treat all patients as potentially infectious and not to base the level of infection control on the appearance or disease status of patient What defines the level of control? – Level of control to be based on type of procedure and reasonably anticipated type of exposure Adaptation of Spaulding’s Classification to clinical surfaces 1. 2. 3. 4. Critical Semi-critical surfaces Non-critical surfaces Environmental surfaces Critical items Sharps that pierce the skin or mucosa Semi-critical Items that enter the mouth but are not sharp Non-critical spray wipe Items that do not enter the mouth but those that are touched often during care spray Spaulding’s Classification of Surfaces 1. 1 2. 2 3. 3 4. 4 Critical: STERILIZATION • Items that pierce skin or mucosa – Explorers, scalpels, scalers, burs & other sharps Semi-Critical: STERILIZATION • Non-sharp items that enter the oral cavity – Amalgam condensers, mirrors, handpiece Non-Critical: DISINFECTION • Items not entering the oral cavity – Bracket table, face-bow, chair controls Environmental: HOUSEKEEPING • Walls, floors and environmental surfaces Environmental surfaces Dusting Sweeping Swabbing Walls, floors, wall hangings that can be managed by housekeeping Other common infection control & safety issues Do’s and Don'ts Do’s and Don'ts Do’s and Don'ts Length Of Nails Acceptable Length Of Nails Questionable No Open Wounds, including Paper-cuts Use a dressing and then wear gloves Common Infectious Diseases in Dentistry • Sexually Transmitted Diseases: • Herpes Simplex – Whitlow, gingivostomatitis, eye infection 1 2 • • • • Goncoccal Infections Chlamydial Infections Trichomonal Infections Syphilis – oral lesions • Infectious Mononucleosis • Hepatitis B, C, D Virus Infections • Human Immunodeficiency Virus Infection 3 4 • Respiratory Diseases: aerosols droplet – Common Cold – Sinusitis – Pharyngitis – Pneumonia – Diphtheria – Tuberculosis Pediatric • Childhood Diseases: – Chickenpox (Varicella) – Herpangina – Hand, foot and mouth disease – Rubella – Rubeola – Mumps – Cytomegalovirus infection lesion blood saliva mucosa droplet aerosol ingestion Common childrens’ diseases Mumps Chicken Pox • Hepatitis A & E (fecal-oral) • Commonly in lesser developed regions • A = picornoviridae, RNA virus – jaundice and rarely death – incubation 4-6 weeks – on recovery, life-long immunity • E = similar to HAV – higher rate among pregnant women Hepatitis • Hepatitis B Infection – DNA Hepadnavirus – Most not clinically identified – USA is Low to moderate in Prevalence – Incubation 45 - 160 days (chronic) – Percutaneous and Non-Percutaneous Infection from Patient <=> Dentist • Outcomes of HBV infection – about 90% show resolution – 9 - 10% become asymptomatic Carriers • suffer from chronic hepatitis • develop hepatocellular carcinoma – about 1% fulminant death – Rate of infection among dentists • 13.6 % to 38.5 % – All DHCW should be immunized • Hepatitis C Infection – Parenterally transmitted Non-A Non-B – Associated with • Blood and Body Fluid – 60 % develop chronic liver disease • of the above, 30-60 % show active liver disease • 5 - 20 % develop cirrhosis of liver Hepatitis-B Virus-Carrier Serology • • • • • Carriers show lower number of symptoms Have a subclinical scenario Are normally HBeAg Positive & Contagious HBsAg & HBeAg in blood precedes jaundice In dentistry it is difficult to clinically identify a patient who is a carrier, therefore Strict IC • Practice Restrictions for HBeAg Positive DHCW Hepatitis B Virus Pretesting & Post-testing • Pretesting (anti-HBs) :• Some are doing the pretesting??? • Post-testing (anti-HBs) :• Testing within 6 months after vaccination • Negative = primary non-responder or responder with low detectable levels but still protected • Booster Doses and Antibody persistence :• Till now, no booster doses in the US Hepatitis D & Hepatitis G • Hepatitis D Infection – Bloodborne virus-like particles – always dependent on HBV infection – either a co-infection or super-infection • Piggy-back Virus – Mode of transmission similar to HBV – Not uncommon during pregnancy • Hepatitis G Infection – Newly identified bloodborne condition Spread of HIV & AIDS 1 2 SE NY NY SF SF CH CH DEN LA LA A D HI HI HO HO PR PR 3 4 HI HI PR M PR High Risk Groups • • • • • • • • Multiple sex partners : Heterosexual, homosexual or bisexual Intravenous Drug users Hemophiliac treatment Blood Transfusion before Spring 1985 Steady sexual partners to the above 4 groups Infants born to people of the above 5 groups Very few risk groups spared Outcomes of Exposure Exposure No Infection Acute Disease Infection Asymptomatic PGL AIDS HIV Seropositive only No AIDS HIV & AIDS-Oral Manifestations • • • • • • • • • Oral hairy Leukoplakia Candidiasis Intraoral KS Associated cervical lymphadenopathy Recurrent herpes simplex virus Papillomas HIV associated gingivitis (HIV-G) HIV associated periodontitis (HIV-P) HIV associated necrotizing gingivitis Risk of Occupational Transmission of HIV • More than 1400 HCWs (with exposure) tested • Of the 1000 with significant exposure, only 4 converted to HIV-seropositive state in 6 months • 100 HCWs with sharp injuries, no conversion • 691 with mucosal contact to Blood and Other Potentially Infection Materials (BOPIM), no conversion • 235 HCWs with 644 sharp injuries, 1 seroconversion SEROCONVERSION RATE IS < 1.0% Tuberculosis • One of the oldest known diseases • Was under control for some time • Back with Vigor as MDR-TB • 8 million people affected every year • 3 million die every year • Insidious symptoms • Periodic testing for dentist and staff 1Robert Robert Louis Stevenson Louis Stevenson's sarcophagus, on top of Mount Vaea, Upolu, Western Samoa. Photo credit-- David Morens. Tuberculosis-Agents & Diseases Common Organisms Diseases M. tuberculosis Pulmonary TB M. bovis Pulmonary TB M. kansasii Pulmonary TB M. fortuitum Cutaneous M. intracellulare Compromised M. avium Rare M. chelonae Rare M. leprae leprosy M. gastri None M. smegmatis None Tuberculosis Signs & Symptoms of Pulmonary TB • Signs and symptoms : • • • • • • • • night sweats malaise weight loss fever fatigue chest pain coughing sputum (possibly blood tinged) cough and above symptoms for more than 3 weeks Tuberculosis Recommendation for Control • Early Identification & Treatment : – Screening questions and test high risk groups – Refer positive cases for Medications and Followup – Defer elective care and refer patient for TB-tests – Refer urgent and emergency patients to facilities equipped to provide care Tuberculosis Recommendation for Control • Surveillance : – Routine TB skin test for all HCWs – Post exposure follow-up and care of HCW and close contacts in the event of exposure Tuberculosis Implications for Dentistry • • • • • BUT : High Aerosol procedures present in dentistry Patients see dentists over many office visits Therefore, may show a higher risk than expected Use PPE, Barriers, HVE, TB-cidal disinfectant, Annual Testing regularly • Defer Elective and Refer for TB care