Chapter 10 - Infection Prevention and Control

Infection prevention and control (IPC)

• Comprehensive and systematic program — reduce risk of transmitting infectious agents

• Infection occurs when: Portal of entry

• IPC breaks chain of infection

  • Clinician → patient

  • Patient → Clinician

  • Patient → patient

Goal of IPC

1. Prevent healthcare associated infections (HAIs) in patients

2. Prevent Occupational injuries and illnesses in healthcare personnel

Infection control assessment

What procedures will be performed?

• Periodontal instrumentation, radiographs, air polishing…

What exposure risks are associated with those procedures?

• Blood, saliva, sharps injury…

What IPC measures are indicated?

• PPE, barriers, hand hygiene…

Procedure → Risk → Protection

Model of IPC vs Dental hygiene care model

IPC model

• Tasks and procedures to protect both patient and provider

DH care model

• Patient’s health needs

→ Don’t rely on patient’s health history to determine infection risk

(Asymptomatic, patient doesn’t know etc)

• COVID, Hep B, C, Influenza

Use standard precautions for EVERYONE

Government Agencies and Organizations

Centers for Disease Control and Prevention (CDC)

• Health and human services department (HHS)

• Promote health, qol, infection guidelines n rec

• Not regulatory agency (NO ENFORCE) only recommendations

Occupational Safety and Health Adminstration (OSHA)

• US Department of Labor

• Enforce/ Regulates workplace safety regulations

• Employers in private sector are responsible for health and safety of employees

National Institute for Occupational Safety and Health (NIOSH)

• Conducts research and makes recommendations to prevent occupational injuries

• Approves respirators

US Food and Drug Administration (FDA)

• Regulates medical products and devices

• Evaluates safety and effectiveness

US Environmental Protection Agency (EPA)

• Regulates environment, hazardous waste, chemicals and disinfectants

Other organizations (non regulatory)

American National Standards Institute (ANSI)

• Standards for protective clothing

• Eyewear

Association for the Advancement of Medical Instrumentation (AAMI)

• Standards for sterilization

• Healthcare facilities

American Dental Association (ADA)

• Develops dental standards and terminology

Organization for Safety, Asepsis and Prevention (OSAP)

• Provides infection prevention resources

Government Agency summary

Organization	Think
CDC	Guidelines/recommendations
OSHA	Workplace safety/regulations
NIOSH	Occupational safety research + respirators
EPA	Environment + disinfectants
FDA	Medical products/devices
ANSI	Standards
AAMI	Instrument sterilization/processing
ADA	Dentistry standards
OSAP	Dental infection-prevention resources

Standard of Care

Minimum acceptable level of care

Can be influenced by

• Infection control regulations

• Evidence based guidelines

• Government agencies

• Licensing boards

• Dental practitioners

• Expert opinions

Types of pathogenic microorganisms dhcp

• Cytomegalovirus (CMV)

• HBV

• HCV

• Herpes

• Simplex virus type 1 and 2

• HIV

• TB

• Staphylococci

• Streptococci

• Influenza

• Coronavirus

Infection through

→ Direct contact w/ blood, oral fluids

→ Indirect contact w/ contaminated objects

→ Droplets

→ Inhalation of aerosols

From

→ Pathogenic organism

→ Reservoir source

→ Mode of transmittion

→ Portal entry

→ Susceptible host

Chain of Infection

Link where disease transmission occurs

Infectious Agent

• Bacteria, virus, fungi

Reservoir

• People, instruments, equipment, water

Portal of Exit

• Secretions, blood, skin, mucous membranes

Transmission

• Direct contact, indirect, fomites, vector, airborne

Portal of Entry

• Mucous membrane, GI Tract, broken skin, eyes

Susceptible Host

• Immunosuppressed, elderly

CDC 4 principles of infection control

Principle 1

• Take action to stay healthy

  • Immunization, hand hygiene, medical evaluation, postexposure management, education, training

Principle 2

• Avoid contact w/ blood and other infectious substances

  • PPE, gloves, face mask, eyewear, gowns, safe handling of sharp instruments and objects & high speed evacs

Principle 3

• Make patient care items safe

  • Cleaning, sterilization, disinfection, containment and disposal of single use items

Principle 4

• Limit spread of blood/ infectious substances

  • Protective covers/barriers, cleaning and disinfecting, waste management of sharps/non sharp and hazardous waste

P1: work restrictions

Work restrictions

• diptheria, mmr = don’t work

• hep a = no direct contact

• upper resp infection = avoid autoimmune contact

• herpes/ shingles = continue work, but cover lesions

• hepb = continue work no restrictions except no oral surgery

• hcp/hiv = not restricted

P1: Immunization recs for Healthcare personnel (HCP)

CDC Advisory council on immunzation practices (ACIP)

→ Rec for all HCP

• HepB (most important)

  • Employer must offer, if employee declines → must sign osha declination waiver

• Influenza

• MMR

• Varicella

• Tdap

→ HCP should consult w/ provider to determine immunization/ risk

→ Children should receive DPT (diptheria, pertusis, tetanus)

→ Adults receive Td (tetanus diptheria) booster every 10 yrs

→ TdaP rec for all adults (Replace Td)

→ 65+ get pneumococcal vaccine

How is Hepatitis B vaccine tested?

3 part series

• HepB vaccine dose 0,1,6 months

• Hepatitis B surface antibody (Anti-HBs) given 1-2 months after third dose

  • If failed then

• Additional dose → Get an anti-HBs titer

  • Fail = nonresponder or test for hepatitis B surface antigen (HBsAg)

  • HBsAg active infection or carrier status

HBsAg = Antigen

Anti-HBs = Antibody against antigen

P2: Standard precautions

• Used for ALL Patients regardless of infection status, symptoms, appearance etc

SP applies to

• Blood

• Bodily fluids / secretions

• Excretions

• Nonintact skin

• Mucous membrane

Health history alone does NOT determine infection risk

P2: Transmission based precautions

• Used in addition to standard precautions

Contact

• Direct or indirect contact

• Person or environment

Droplet

• Respiratory droplets

Airborne

• Infectious particles suspended in air

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Precautions may include

• Patient isolation

• Adequate room ventilation

• Respiratory protection N95

Tuberculosis (TB) — active

• Patient should wear surgical mask when coughing/ sneezing

• Defer dental treatment for treatment

• Emergency dental → transfer to TB facility equipped w/ engineering controls

Tests

• Tuberculin skin test (TST) / Mantoux test

P2: Engineering controls

• Most effective workplace control

• Devices/ equipment that remove hazard

Examples (Refer to photo)

• Safety needles

• Retractable needles

• Needle-shielding devices

• Safety IV devices

• Sharps containers

• Devices that contain/remove sharps

P2: Work practice controls

• How the person performs the task

Examples (Refer to photo)

• Never recap needles by hand

• Avoid hand contact w/ sharps

• Proper patient positioning

• 1 handed scoop method for anesthetic needles

• High speed evacuator and ultrasonic disinfector

P2: Administrative controls

• Policies and organizational actions

  • Rotating duties

  • Taking breaks

  • Employee education and training

P2: Personal protective equipment (PPE)

• Protective clothing, eyewear, airway, attire

• Based on exposure risk

  • Procedures like scaling/root planning will produce more risk than xrays

Protects from

• Blood, splatter, saliva, bodily fluids, aerosols

→ Engineering and work practice controls are preferred, PPE is not your ONLY line of defense

Eye and face protection

• Goggles, safety glasses w/ side shields, face shields

• Protects from splatter, droplets etc

Masks (Surgical not respirators)

• Protects mouth/ nose from splatters/droplets

American Society for Testing and Materials (ASTM)

• Level 1 = lowest barrier performance

  • For procedures w/ no/ minimal blood splatter (not used for DH)

• Level 2 = intermediate

• Level 3 = highest

Surgical mask ≠ respirator

Respirators & Respiratory protection

• N95 (NIOSH approved)

• Used for aerosol generating procedures (handpieces, airwater syringes, air polishing, ultrasonic)

Respiratory protection program

• Fit testing

• Medical evaluation

• Education

• Training

Protective clothing

• Gowns, lab coats, uniform

• Cover forearmsand below knees

• Scrubs are not protective clothing

Gloves

Medical examination gloves (nitrile)

• Ambidextrous, nonsurgical, nonsterile

• For contacting blood, saliva, OPIM

Sterile surgical gloves

• Sterile, for surgical procedures

Heavy duty utility gloves

• Puncture resistant for sharps injury

• Used for cleaning contaminated instruments/ equipment

Hand hygiene

Type	Main purpose
Routine handwash	Remove soil and transient microorganisms soap + water
Antiseptic handwash	Remove transient + reduce resident flora
Antiseptic handrub	Not visibly soiled
Surgical hand antisepsis	Remove transient + resident flora

Transient flora

• Patients, contaminated surfaces, environment

• Easy to remove

• Wash hands

Resident flora

• Organisms that live on/ in the body

• Hard to remove

• need antiseptic agents

Types of procedures

• Routine dental procedures (Screening, examination, nonsurgical)

  • Soap + water

• Not soiled

  • Alcohol based rub

• Surgical procedures (biopsy, extraction)

  • Hand antisepsis

Other precautions

• Don’t wear rings

• Keep nails short/ no fake nails

• Prevent dermatitis

  • Powder free gloves

  • Hand lotion

  • Cool water

Principle 3: Make patient care items safe

• Cleaned, sterilized, disinfect, dispose single use

Sterilization

• Destruction of all living organisms including bacterial spores

Instrument classification

Critical

• Penetrates soft tissue/ bone

• Sterilization

  • periodontal scalers, dental instruments

Semicritical

• Contacts mucous membrane or nonintact skin

• Sterilization or high level disinfectant (if no heat)

  • Dental mirrors, handpieces

Noncritical

• Contacts intact skin

• Clean/ disinfect/ barrier w/ EPA intermediate level disinfectant

  • Xrays, blood pressure cuff, facebow

Sterilization process

Transport

• Container w/ solid sides and bottom

• Biohazard label

• Separate dirty from sterile instruments

Cleaning

• Clean before sterilization (debris intefere w/ sterilization)

• Use automatic cleaning methods

  • Ultrasonic cleaning baths

  • Instrument washers/ disinfectors

• Manual cleaning

  • Use utility gloves/ eye, mask, gown

Packaging

• Inspect, dry, package, place in sterilizer

• Don’t overload or overlap

Sterilization

• Autocalve (steam + pressure)

  • Distilled water → Air evac via dynamic (preferred) air removal or gravity displacement

  • 4-6 mins + 20 min drying

• Unsaturated chemical vapor

  • Use chemical vapor instead of steam

  • Reduces humidity and rust/corrosion

• Dry heat

  • Uses high heat 350F

  • Damages heat sensitive items

Storage

Must be 1 directional workflow to reduce contamination

Sterility assurance

Chemical indicators

• Doesn’t prove sterilization was successful

• Tells you if conditions were reached

Biological indicators (BIs)

• Spore test

  • geobacillus stearothermophilus

  • bacillus pumilus

• Highest level of sterility assurance

• Test weekly

Dental water quality

• Safe drinking — Managed by EPA

• Must be ≤ 500 CFU/mL for drinking water

  • CFU = colony forming units

• Have a separate water reservoir

• Biofilm can still develop inside of dental unit waterlines even if you’re using distilled/ sterile water

Chemical treatment/ products

• Remove biofilm via shock treatment

• always follow manufacturer’s instructions for use (IFU)

2 types of treatment

• Treatment cartridges (release active ingredients to disinfect)

• Filter devices (removes solids)

  • Filters help remove microorganisms as it exits the waterline. Does NOT remove biolfilm

Surgical procedures

• Only use sterile solutions (coolants/ irrigants)

• Sterile tubing/ bulbs

Principle 4: Limit spread of blood/ infectious substances

• PPE, cleaning, disinfecting, limit touching while wearing medical gloves, manage waste

Environment surface disinfection

Housekeeping surfaces

• Floors, walls, sinks

• Lower risk of disease transmission

• Clean/ disinfect if visibly contaminated

Clinical contact surfaces

• Surfaces contaminated with droplets, oral fluids etc

• Must be barrier protected/ cleaned/ disinfect between each patient

• No barriers = use low level disinfectant or intermediate level w/ tuberculocidal claim

Exposure management

• Occupational exposure is preventable

• Qualified healthcare provider (QHCP) - evaluates and treat infectious disease

Postexposure management program

• Must be in every dental facility

Post exposure management

Step 1 - Immediate first aid

• Wash the area

• don’t use antiseptic or milk the wound

Step 2 - Report the incident

• Report to designated person

• Person completes form (source patient, nature of exposure)

Step 3 - Discuss w/ source patient

Step 4 - Referral

• Refer to QHCP to treat exposed person

Step 5 - Medical evaluation and follow up

• Test for disease and followup depending on results (type of exposure, amount of fluid, infectious status, susceptibility)

• HBV - vaccinate if unvac, treatment within 24 hrs, if vac but no response, no action needed

• HCV - no vaccine

• HIV - Give HIV PEP within 2 hrs