Download Infection Control - Stony Brook School of Dental Medicine

INFECTION CONTROL
TRAINING
Susan Chiofolo RDH
Rachel Vinci RDH, BS
WHY IS INFECTION CONTROL
IMPORTANT IN DENTISTRY?
• Both patients and Dental Health Care Personnel (DHCP)
can be exposed to Pathogens
• Contact with blood, oral and respiratory secretions, and
contaminated equipment occurs
• Proper procedures can prevent transmission of infections to
patients, DHCP, and their families
Definition: a biological, physical, or chemical
agent capable of causing disease
Biological agents may be bacteria, viruses,
fungi, protozoa, prions or helminthes.
Bloodborne Pathogens
Bloodborne viruses such as HBV, HCV, and HIV
are transmissible in health care settings. They
can produce chronic infections and are
often carried by persons unaware of infection.
Carriers: Hosts without obvious illness
It is very common for infections to occur without a disease developing. The
person infected can potentially spread the pathogen, but does not show clear
symptoms. These hosts are called carriers and maybe unaware that they can
transmit pathogens to others.
A latent infection is a situation in which a virus is present in the body, but it
remains dormant, not causing any overt symptoms. The patient is still infected
with the virus, and he or she can pass the virus on to others when they are
exposed to the dormant virus. Latent infections can also be activated, causing
symptoms and illness to emerge again. A classic example of a latent infection is
herpes simplex, which periodically flares up to cause cold sores before going
dormant again.
• Tuberculosis
• Tetanus
Survives for up
to 3 weeks
• Herpes
Simplex
• CJD and
vCJD
Hepatitis
A
(HAV)
Hepatitis
B
(HBV)
Hepatitis
C
(HCV)
HIV
Survives for 1
week on surfaces
• Staphylococcus
• German
Measles
Hepatitis B
Was the highest occupational risk for dental
professionals! Vaccinations for Hepatitis B has greatly
reduced the risk!
Important
diseases to
dental
professionals
OTHER IMPORTANT DISEASES
ZIKA
No Vaccine exists

Health care personnel should
adhere to Standard Precautions in
contact and after removing PPE,
including gloves
EBOLA
Symptoms of Ebola include:

Fever

Severe headache

Muscle pain

Weakness

Patients may be asymptomatic

Fatigue

The most common symptoms of
Zika are fever, rash, joint pain, or
conjunctivitis (red eyes). Other
common symptoms include muscle
pain and headache. The incubation
period (the time from exposure to
symptoms) for Zika virus disease is
not known, but is likely to be a few
days to a week

Diarrhea

Vomiting

Abdominal (stomach) pain

Unexplained hemorrhage (bleeding
or bruising)

Symptoms may appear anywhere
from 2 to 21 days after exposure to
Ebola, but the average is 8 to 10
days

Can be transmitted through saliva
CHAIN OF INFECTION
RESERVOIR:
WHERE A PATHOGEN CAN SURVIVE
OR REPRODUCE
Portal of Exit: How a Pathogen leaves the reservoir
 coughing
 Sneezing
 Oral draining lesions
•
•
•
•
Direct contact with blood or body fluids
Indirect contact with a contaminated
instrument or surface
Contact of mucosa of the eyes, nose or
mouth with droplets or spatter
Inhalation of airborne microorganisms
Portal of Entry
Broken Skin
To cause infection, a pathogen must have a portal of
entry (or means of getting into the body)
The portals of entry for airborne pathogens are the
mouth and nose
Blood-borne pathogens must have access to the
blood supply to gain entry into the body
This occurs through a break in the skin caused by
a needle stick, a cut, or even a human bite
Can also occur through mucous membranes of
nose and oral cavity
Respiratory
Mucous Membrane
HIGH RISK PATIENTS:
IMMUNOCOMPROMISED
Existing disease
Previous surgery
History of radiation or chemotherapy
Immune deficiency
ELDERLY/YOUNG
Infection Control
Pathogen
Source
Transmission
Entry
Break any link in the chain
To prevent the spread of infection
Host
STANDARD PRECAUTIONS

APPLY TO ALL PATIENTS

INCLUDE BODY FLUIDS, SECRETIONS. AND
EXCRETIONS EXCEPT SWEAT, WHETHER THEY
CONTAIN BLOOD OR NOT

NON-INTACT/BROKEN SKIN

MUCOUS MEMBRANES
• HANDWASHING
• USE OF GLOVES, MASKS, EYE PROTECTION, AND
GOWNS
• PATIENT CARE EQUIPMENT
• ENVIRONMENTAL SERVICES
• INJURY PREVENTION
FACTORS AFFECTING EXPOSURE RISKS
HOST FACTORS
 Natural Barriers: intact skin
 Immune System: healthy vs. immunocompromised
 Foreign prosthetics: artificial joint, pig valve,
chemotherapy ports
 Age: very young, elderly
 Occupation: health care workers
 Lifestyle: college students(stress)
IF SALIVA WERE RED VIDEO
https://www.youtube.com/watch?v=YjWwQdfZd1I
Click here to
watch
19
DISEASE TRANSMISSION IN THE
DENTAL OFFICE
• Every dental office should have an infection control program
designed to prevent the transmission of disease from:
• Patient to dental team
• Dental team to patient
• Patient to patient
• Dental office to community
(including dental team’s family)
• Community to dental office to patient
20
PATIENT TO DENTAL TEAM
• Most common route is through direct contact (touching) of the patient’s
blood or saliva
• Droplet infection occurs through mucosal surfaces of the eyes, nose, and
mouth
• Can occur when the dental-team member inhales aerosol generated by the
dental handpiece or air-water syringe
• Indirect contact occurs when the team member touches a contaminated
surface or instrument
21
PATIENT TO DENTAL TEAM (CONT.)
• Ways to prevent disease transmission from the patient to the dental team
member:
•
•
•
•
•
Gloves
Handwashing
Masks
Rubber dams
Patient mouthrinses
22
DENTAL TEAM TO PATIENT
• Very unlikely to happen
• Can result if the dental team member has lesions on the hands, or if the
hands are cut while in the patient’s mouth, permitting the transfer of
microorganisms
• Infection control measures that help to prevent team-to-patient transmission
include:
•
•
•
•
Masks
Gloves
Handwashing
Immunization
23
PATIENT TO PATIENT
• Has occurred in the medical field, but no cases of this type of transmission
have been documented in dentistry
• Although such transmission is possible, contamination from instruments used
on one patient must be transferred to another patient for this to occur
• Infection control measures that can prevent patient-to-patient transmission
include:
•
•
•
•
•
Instrument sterilization
Surface barriers
Handwashing
Gloves
Use of sterile instruments
24
DENTAL OFFICE TO COMMUNITY
• Microorganisms can leave the dental office and enter the community in a
variety of ways:
• Contaminated impressions sent to the dental laboratory
• Contaminated equipment sent out for repair
• In theory, transportation of microorganisms out of the office on the dental team’s
clothing or hair
• The following measures can prevent this type of disease transmission:
• Handwashing
• Changing clothes before leaving the office
• Disinfecting impressions and contaminated equipment before such items leave
the office
DENTAL WATERLINES
Can be a source of serious infection.
In 2012 an 82-year-old otherwise healthy woman developed Legionnaire’s
disease after a dental visit, which has been attributed to contaminated
waterlines.
In 2015, a cluster of pediatric patients were discovered to
have Mycobacterium abscessus odontogenic infections, which were traced
back to the water used in the pediatric practice. 20 cases were confirmed. All
patients were severely ill, requiring hospitalization 17 patients required surgical
excision and 10 received outpatient intravenous antibiotics). As of April 5,
2016, no deaths have resulted from infection.
To prevent infections associated with waterlines, dental practices should follow
manufacturer guidelines to disinfect waterlines, monitor water quality to ensure
recommended bacterial counts, use point-of-use water filters, and eliminate
dead ends in plumbing where stagnant water can enable biofilm formation.
26
COMMUNITY TO DENTAL OFFICE
TO PATIENT TRANSMISSION
• Microorganisms enter the dental office through the municipal water that
supplies the dental unit
• Waterborne organisms colonize the inside of the dental unit waterlines and form
biofilm
• As water flows through the handpiece, air-water syringe, and ultrasonic scaler, a
patient could swallow contaminated water
Wash for at least 15 seconds
1ST WAY TO BREAK MODE OF TRANSMISSION
You can sing the happy birthday song to yourself
https://www.youtube.com/watch?v=sJfsyhQ0oBs
Click here to
watch
28
HAND HYGIENE: HANDWASHING
GUIDELINES
• Wash your hands each time before you put on gloves and
immediately after you remove gloves
• Wash your hands when you inadvertently touch
contaminated objects or surfaces while barehanded
• Always use liquid soap during handwashing
• Bar soap should never be used because it may transmit
contamination
• Dry hands well before donning gloves
29
From Samaranayake LP: Essential microbiology for dentistry, ed 4, New York, 2014, Churchill Livingstone
HANDS NEED TO BE CLEANED WHEN:
VISIBLY DIRTY
AFTER TOUCHING CONTAMINATED ITEMS WITH BARE
HANDS
BEFORE AND AFTER PATIENT TREATMENT(WITH OR
WITHOUT GLOVES)
31
ADDITIONAL HANDWASHING
GUIDELINES
• Keep nails short and well-manicured
• Rings (except for wedding rings), fingernail polish,
and artificial nails are not to be worn at work
• Dental personnel with open sores or weeping
dermatitis must avoid activities involving direct
patient contact and handling contaminated
instruments or equipment until the condition on the
hands is healed
ALCOHOL-BASED HAND RUBS
• Waterless antiseptic agents are alcohol-based products that are
available in gels, foams, or rinses
• The product is applied to the hands, which are then rubbed together
to cover all surfaces until dry
• These products are more effective at reducing microbial flora than
plain soap
• Concentrations of 60% to 95% are the most effective
• They contain emollients that reduce the incidence of chapping,
irritation, and drying of the skin
• These products are very “dose sensitive”
• If your hands are not visibly soiled, you may use a waterless alcoholbased hand rub
32
33
PERSONAL PROTECTIVE
EQUIPMENT
• OSHA requires the employer to provide employees with the appropriate
personal protective equipment (PPE) without charge to the employee
• Examples of PPE:
•
•
•
•
•
•
Protective clothing
Surgical masks
Face shields
Protective eyewear
Disposable patient-treatment gloves
Heavy-duty utility gloves
34
PROTECTIVE CLOTHING
• The purpose of protective clothing is to protect the skin and underclothing
from exposure to saliva, blood, aerosol, and other contaminated materials
• Types of protective clothing include:
• Smocks, slacks, skirts, laboratory coats, surgical scrubs (hospital operating room
clothing), scrub (surgical) hats, pants, and shoe covers
• The type of protective clothing you should wear is based on the degree of
anticipated exposure to infectious materials
• The BBP prohibits the employee from taking protective clothing home to be
laundered
35
PROTECTIVE CLOTHING
REQUIREMENTS
• Protective clothing should be made of fluid-resistant material
• As a means of minimizing the amount of uncovered skin, clothing should
have long sleeves and a high neckline
• The design of the sleeve should allow the cuff to be tucked inside the band
of the glove
• During high-risk procedures, protective clothing must cover dental personnel
at least to the knees when seated
• Buttons, trim, zippers, and other ornamentation should be kept to a minimum
Lab coats, gowns, gloves,
eyeglasses with side shields,
hair tied up
Even while doing lab work
37
HANDLING CONTAMINATED
LAUNDRY
• The BBP Standard states the protective clothing may not be taken home
and washed by employees
• It may be laundered in the office if the equipment is available and if
Standard Precautions are followed for handling and laundering the
contaminated clothing
• Contaminated linens that are removed from the office for laundering should
be placed in a leakproof bag with a biohazard label or an appropriately
color-coded label
• Disposable gowns must be discarded daily and more often if visibly soiled
PROTECTIVE MASKS
38
• Worn over the nose and mouth to protect you from inhaling
possible infectious organisms spread by the aerosol spray of the
handpiece or air-water syringe and accidental splashes
• Not to be twisted around ears. This allows aerosols to enter and
then you inhale contaminates.
• Masks should be changed for every patient or more often (CDC
guideline)
• To handle a mask, touch the side edges only; avoid contact with
the more heavily contaminated body of the mask
• The mask should conform well to the face
• The mask should not make contact with the mouth while being
worn because the moisture that is generated will decrease
filtration efficiency
• A damp or wet mask is not an effective mask
MASK INFORMATION
Wear the proper mask according to the
intended procedure
ASTM LEVEL 1
ASTM LEVEL 2
ASTM LEVEL 3
• Oral exams for low-risk
patients
• Procedures involving low
levels of spray and splatter
• Orthodontic treatment
with little or no spray
• Hand instrumentation with
little or no instrument spray
• Fluoride treatments
• Basic lab work
• Oral exams for known
higher risk patients
• Procedures involving
moderate levels of spray,
splatter and airborne
particles
• High or low speed
handpieces
• Dry, low aerosol procedures
• Bleaching, orthodontic,
and periodontic
procedures
• Lab work with exposure to
blood or contaminated
materials
• Oral exams for high-risk
patients
• Procedures involving high
levels of spray, splatter and
airborne particles
• Ultrasonic scalers and high
speed aerosols
• Procedures involving heavy
use of air polishers and airwater syringes
• Oral surgery (tooth extractions,
maxo/facial reconstruction)
40
PROTECTIVE EYEWEAR
• Worn to protect eyes against the danger of damage caused by
aerosolized pathogens
• Also prevents spattered solutions or caustic chemicals from injuring the
eyes
• OSHA requires the use of eyewear with both front and side protection
(solid side shields) during exposure-prone procedures
• If you wear contact lenses, you must wear protective eyewear with
side shields or a face shield
• After each treatment or patient visit, clean and decontaminate your
protective eyewear in accordance with the manufacturer's
instructions (CDC guideline)
• All patients should wear protective eyewear (goggles)during their
treatment
41
PATIENT EYEWEAR/GOGGLES
• Patients should be provided with protective eyewear
because they also may be subject to eye damage during
the procedure
• This may result from:
• Handpiece spatter
• Spilled or splashed dental materials, including caustic
chemical agents
• Airborne bits of acrylic or tooth fragments
42
FACE SHIELDS
• A chin-length plastic face shield may be worn as an
alternative to protective eyewear
• A shield cannot be substituted for a face mask because it
does not protect against inhalation of contaminated
aerosols
• When splashing or spattering of blood or other body fluids is
likely during a procedure (such as surgery), a face shield is
often worn in addition to a protective mask
43
GLOVES
• Because dental personnel are most likely to come into
contact with blood or contaminated items with their hands,
gloves may be the most critical PPE
• You must wear a new pair of gloves for each patient,
remove them promptly after use, and wash your hands
immediately to avoid the transfer of microorganisms to
other patients or the environment (CDC guideline)
• Consult with the glove manufacturer regarding the
chemical compatibility of the glove material and the dental
materials you use (CDC guideline)
Dental health care personnel wear gloves to prevent
contamination of their hands when touching mucous
membranes, blood, saliva, or other potentially infectious
materials and to reduce the likelihood that microorganisms
on their hands will be transmitted to patients during dental
patient-care procedures. The safest dental visit would
include not touching sterile instruments with bare hands.
Please remember to don gloves when touching instruments
to be used on a patient.
GUIDELINES FOR THE USE OF
EXAMINATION GLOVES
• All gloves used in patient care must be discarded after a
single use
• These gloves may not be washed, disinfected, or sterilized
• Latex, vinyl, or Nitrile gloves may be used for patient
examinations and dental procedures
• Torn or damaged gloves must be replaced immediately
• Surgical Gloves are used for all surgical procedures
45
GUIDELINES FOR THE USE OF
EXAMINATION GLOVES (CONT.)
• Do not wear jewelry under gloves (a wedding band is
permissible)
• Change gloves frequently
• Remove contaminated gloves before leaving the chairside
during patient care and replace them with new gloves
before returning to patient care
• Hands must be washed after glove removal and before
regloving
46
Not washing your hands and wearing gloves = susceptible to contract herpetic whitlows,
herpes, and eye infections. Protect yourself, your patients, and your family members!
STERILE SURGICAL GLOVES
• Sterile gloves should be worn for
invasive procedures involving the
cutting of bone or significant amounts
of blood or saliva, such as oral surgery
or periodontal treatment
• Sterile gloves are supplied in
prepackaged units to maintain their
sterility before use
• They are provided in specific sizes and
are fitted to the left or right hand
48
MAINTAINING INFECTION
CONTROL WHILE GLOVED
49
• During a dental procedure, it may be necessary to touch surfaces or objects
such as drawer handles and material containers
• If you touch these objects with a gloved hand, both the surface and glove
become contaminated
• To minimize the possibility of cross-contamination, use an overglove when it is
necessary to touch a surface
• Opening drawers and cabinets
• Set up instruments, medications, and impression materials ahead of time,
and use disposable and unit-dose items whenever possible
• Opening containers
• When opening a container, use overgloves, a paper towel, or a sterile
gauze sponge to remove the lid or cap
• Use sterile cotton pliers to remove an item from the container
Placement of PPE
1. PPE coat over scrubs
2. Mask placed
3. Eye protection
4. Hands washed
5. Gloves on
Removal of PPE
1. Remove soiled gloves
2. Remove eyewear place on paper towel to clean
3. Remove mask
4. wash your hands
1.
2.
3.
4.
5.
Wash hands when entering clinic prior to setting up for the day
Do Not leave cubicle wearing gloves unless transporting contaminated items
Do Not Hang masks around chin or in wear in hallway
Do Not wear disposable gowns in hallways
Lab coats are acceptable in hallways but not in nonclinical areas:
(café, bathrooms, lab, office areas)
5. Do Not wear gloves while accessing bay carts or mobile carts
6. Always wash your hands when removing gloves
7. Never have food or drink in the clinic
8. Hair must be tied up and off shoulders
IFU
• What is It?
• Why do we need to know about it?
• Where do you get them?
• Why are they important?
• IFU stands for Instructions for use
• Compliance with medical device
manufacturer's instructions for use (IFU)
is a critical aspect of patient safety.
• Reusable medical devices and
instruments must be processed
according to manufacturers instructions
Medical Device Regulations:
Require dental manufacturers to have a
written IFU(Instructions For Use)
This will give instructions for:
• Cleaning
• Disinfection
• Testing
• Packaging
• Sterilizing
• Drying
Failure to follow scientifically accepted
infection control techniques is
“unprofessional conduct” in New York
State.
Rules of the Board of Regents”
section 29.2(a)(13)
Licensed dentists and dental hygienists must
comply with the above rules and may be
subject to disciplinary action if found in noncompliance by the
Office of the Professions.
The Mobile Cart
Shall serve primarily as a mobile work surface
during the treatment period
Students/Residents shall not open drawers or
reach into the cart with contaminated
gloves, therefore no barriers needed on
handles
Paper cover with 2 pieces of barrier tape
and bag
Filtered water stations can be found:
Bay G/H share back wall connecting
the two bays
Bay F end of bay by Urgent Care
dispensary
Bay A bays ABC share wall closest to
waiting room
Pedo Bay on wall between separate
rooms and student operatories
Bay K by Pros and Perio next to the
GPR dispensary
Oral Surgery first room faucet labeled
dental ( the other faucet is labeled
for autoclave and only used in an
autoclave)
Water bottles should be filled at the start of each session and emptied and allowed
to dry every Friday. Water lines must be purged for 2 minutes at the start of each
day and for 30 seconds in-between patients. Remember to purge unused air water
syringes and hand piece lines to prevent backup of stagnant water.
The Operatory Counters
All surfaces should be free of dirt or debris
and have been wiped with moist
disinfectant wipes
The non-working side is usually the side
furthest from the student/resident when
they are seated.
The working side is close to the
student/resident so they can reach for the
required material and continue to treat
the patient.
Supplies such as impression material,
polycarbonate crown boxes etc. are
placed on the non-working side . Gloves
have to be removed to handle anything
on the non-working side .
On completion of patient care….
The Dental Chair, Cart, Light and Counter Surface:
• All plastic barriers must be removed and all
contaminated surfaces should be cleaned
with a saturated disinfectant wipe. A second
wipe should be used to disinfect all surfaces.
• Chair should be raised to its highest point
• Wash hands before leaving the clinic area
INFECTION CONTROL PROTOCOL FOR DENTURE POLISHING IN CLINIC
 A sterilized polishing rag wheel and a single serve
cup of pumice must be acquired from Main
Dispensary
 Add sufficient water to the pumice
 Disinfect the patients denture with Cavicide for 3
minutes
 Ensure the lathe is cleaned before use (shield
and table should be wiped down)
 Place a headrest cover over the tray
 When finished, rinse the denture thoroughly,
discard pumice and disposables, spray and wipe
down unit and return the rag wheel to
Sterilization for reprocessing
Laboratory Protocol
• All cases entering the laboratory, through the
laboratory window will be disinfected and
placed in a plastic bag (including models,
impressions, and bite registrations)
• They can be brought to the lab window three
times a day during lab hours
• All cases in progress, which are released from
the laboratory to the student/resident, should be
disinfected by the student/resident, prior to
delivery to a patient
Impressions should be
disinfected:
Rinse impressions carefully and continuously for
2 Full minutes (to remove the bioburden)
Spray liberally with hospital grade disinfectant
over all sides of the impression and tray
Allow impression to sit 3 minutes in a headrest
cover
Rinse for 1 minute
Wrap impression in a wet paper towel, place in
a clean headrest cover for transport to the lab
DON’T!
PLACE PILES OF MASKS
HAVE FOOD OR DRINK IN CLINIC
CLEAN WITH UNGLOVED HANDS
STORE SUPPLIES AND/OR DRINKS IN CABINET
WEAR AN ILLFITTING MASK
DISCARD MASK IMPROPERLY
DO NOT OPEN INSTRUMENTS
UNTIL PATIENT IS SEATED
TAKE PRIDE IN YOUR WORKSPACE!
DO:
Barrier wrap and tape
all touch surfaces
Medical Waste
Is not considered infectious and can be
discarded in regular waste bin.
What should I
place in the
regulated waste
container?
Regulated Medical Waste
Poses a potential risk of infection during
handling and disposal.
Includes sharps, (needles, scalpel blades, carpules,
burs, endodontic files)
Extracted teeth containing
amalgam restorations must not
be disposed of in RMW which is
destined to be incinerated. A
separate container is provided
for disposal of these teeth.
Please bring to main sterilization
for proper disposal
Blood soaked and blood caked items and human tissue
including extracted teeth. Contaminated items that would
release blood or other potentially infectious material if
compressed. (all body fluids, except sweat.)
Improper handling of used syringes
Proper recapping of used syringes
Post Exposure Protocol
An incident in which an individual has been exposed to possible infectious
material must be cleaned with soap and water and reported to
supervising faculty as soon as possible. This includes any exposure to blood
or saliva, through mucosal contact(*mouth, eyes, or nose), or may have
entered through the individual skin as a result of a puncture or scrape by a
sharp instrument that results in bleeding from an instrument or device used
in patient’s mouth.
Medical care after incident must be followed by a visit to:
Occupational Medicine located at:
2500 Nesconset Highway, Suite 9D, Stony Brook, N.Y. 11790
Telephone # 444-6250
Critical
• Items used to penetrate soft tissue or bone
• Greatest risk of transmitting infection and must be heat
sterilized
Semicritical
• Touch mucous membranes or nonintact skin
• Lower transmission risk but should be heat sterilized if heat
tolerant
Noncritical
• Contact only intact skin
• Low risk of infection transmission
• Cleaned and processed with hospital grade
intermediate/low level disinfectant
Remediation
The first infection control infraction
(violation) will result in a recorded
warning
A second infraction will result in the DHCP
being required to review the clinic
protocol video and passage of an exam
A third infraction will result in removal
from one clinic session, student will be
required to assist in sterilization during
this clinic session
If further violations, the student will be
referred to the Academic Standing
Committee for discussion and action