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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