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Chapter 5: Infection Control and Transmissible Diseases

• Healthcare Providers

  • Infections and communicable diseases can lead to illness, disability, and loss of work time.
  • Objective of the Dental Healthcare Professional is to protect patients and others who may become exposed to infectious agents in the clinical environment.

• Immunity and Vaccines

  • Immunity: Occurs when the immune system develops antibodies to eliminate the antigen.
  • Passive Immunity: Protection from one person to another (e.g., from mother to baby).
  • Active Immunity: Protection acquired in the body by having the disease and recovering from it, or by vaccination.

• Microorganisms of the Oral Cavity

  • Origin: In utero, the oral cavity is sterile, but after birth, microorganisms are transmitted to the infant from the mother or other caretakers.

• Infection Potential

  • Pathogenic, potential pathogenic, or nonpathogenic microorganisms may be present in the oral cavity of each patient.
  • Patients may be carriers of certain diseases but show no signs or symptoms.

• Cross-Contamination

  • Spread of microorganisms from one source to another can occur due to inappropriate work practices such as:
  • Careless handwashing.
  • Inadequate sterilization and handling of sterilized instruments.
  • Inadequate/inappropriate personal protective equipment (PPE).

• Standard Precautions

  • Applies to any procedure involving:
  • Blood
  • Saliva
  • Broken skin
  • Mucous membranes
  • All body fluids, except sweat, even if they do not contain visible blood.
  • Represents the minimum standard of care to protect dental healthcare providers and prevent transmission between themselves and patients.

• Transmission-Based Precautions

  • Used in addition to standard precautions when a patient has or is suspected of having a disease that can spread through:
  • Droplet
  • Contact
  • Airborne
  • Sharps

• Transmission Precautions Details

  • Droplet: Prevent diseases from close respiratory or mucous membrane contact with respiratory secretions through airborne droplets.
  • Contact: Prevent disease transmission from direct or indirect contact.
  • Airborne: Prevent transmission of diseases that remain infectious while suspended in the air.
  • Sharps: Prevent bloodborne pathogen transmission.

• Airborne Transmission

  • Droplet nuclei: <5µm
  • Droplets: 5-100µm
  • Spatter: >100µm (can be inhaled)
  • All dental procedures produce contamination in the form of aerosols, ranging in size from 1 to 100µm; larger particles can land on face and eyes but are not inhaled.

• Management of Airborne Transmission

  • High-volume intraoral suctioning with sonic instrumentation and air polishing.
  • Routine preprocedural rinsing for at least 30 seconds.

• Bloodborne Transmission

  • Most concerns for the dental hygienist.
  • Hepatitis B: Has a vaccine; transmitted through contaminated sharps and sexual contact.
  • Hepatitis C: No vaccine; transmitted through contaminated sharps and sexual contact.
  • HIV: No vaccine available.

• Management of Bloodborne Transmission

  • Adherence to sharps protocols.
  • Use of puncture-resistant gloves when handling contaminated instruments.

• Infectious Process

  • A chain of events is required for the spread of an infectious agent:
  1. Infectious agent
  2. Reservoir
  3. Port of exit
  4. Mode of transmission
  5. Port of entry
  6. Susceptible host

• Types of Infectious Agents

  • Bacteria
  • Viruses
  • Fungi
  • Protozoa
  • Helminths
  • Prions
  • Each type has its specific reaction in an infected host.

• Reservoirs

  • People: respiratory secretions and blood.
  • Equipment: instruments.
  • Dental Unit Water Lines: potential for specific bacteria such as Legionella pneumophila.

• Port of Exit

  • Routes include coughing, sneezing, speaking, and bleeding periodontium.
  • Aerosol-generating procedures include ultrasonic scaling, air polishing, high/low handpieces, and air/water syringes.

• Modes of Transmission

  • Direct Contact: Person to person (e.g., coughing, sneezing).
  • Indirect Contact: Contaminated hands or sharps injury leads to the need for immediate washing with antimicrobial soap and informing the employer for testing arrangements.

• Port of Entry

  • Similar to the port of exit, includes:
  • Body fluids
  • Skin and mucous membranes
  • Droplets and spatter
  • Needlesticks
  • Inhalation
  • Eyes

• Susceptible Host Characteristics

  • Immunosuppressed individuals
  • Medically compromised patients
  • Elderly individuals
  • Individuals with pre-existing transmissible diseases
  • Nonvaccinated individuals

• Most Important Statement:

  • Break the Chain!

• Maintain Infection Control Protocols

  • Utilize official guidelines from:
  • Centers for Disease Control and Prevention (CDC)
  • State public health agencies
  • Occupational Safety and Health Administration (OSHA)

Chapter 6: Exposure Control: Barriers for Patient and Clinician

• Personal Protection for the Dental Team

  • Immunizations are critical for healthcare providers.
  • Protective clothing must be worn, and records must be maintained.

• Personal Protective Equipment (PPE)

  • PPE for the Clinician (Order):
  • Protective Clothing (Scrubs/Hair Covering - Optional)
  • Gowns (Fluid Resistant) or Lab Jacket
  • Mask (Surgical/Respirator)
  • Protective Eyewear (Safety goggles/Dental loupes/Eyeglasses with side shields)
  • Face shield (if needed)
  • Gloves

• Masks

  • Should be changed for each patient.
  • Should be changed if it becomes wet or soiled.
  • Ideally changed every hour when possible.

• Protective Eyewear

  • Various examples of protective eyewear exist.

• Face Shield

  • Must be worn over a regular mask during aerosol-producing procedures (e.g., handpiece, ultrasonic scaler, or air polishing).

• Gloves

  • Criteria for selection of treatment/examination gloves include:
  • Safety factors
  • Ergonomic factors
  • No interference with tactile sense
  • Must not exert a tight pull on the skin
  • Effective barrier capability
  • Strength and durability
  • Must be nonirritating and impervious
  • Materials:
  • Latex and Nonlatex Options: Neoprene, block copolymer, vinyl, N-nitrile
  • For patient care: Nonsterile single-use exam/treatment gloves (latex or nonlatex) and presterilized single-use surgical gloves (latex or nonlatex).
  • Utility Gloves: Heavy-duty latex/nonlatex (puncture resistant for clinic cleanup) and plastic food handler's gloves (over glove).

• PPE for the Patient

  • Includes protective eyewear and a patient bib.

• Fingernail Standards

  • Must be kept short; no artificial nails.
  • Wristwatch and jewelry should not be worn during procedures.

• Methods of Hand Hygiene

  • Routine Handwash: For routine dental examinations and nonsurgical procedures, utilizing water and nonantimicrobial soap.
  • Antiseptic Handwash: Uses water and antimicrobial soap to remove or destroy transient microorganisms and reduce resident flora.
  • Antiseptic Hand Rub: Utilizes hand rub containing 60-95% ethanol or isopropanol (alcohol-based) to remove or destroy transient microorganisms.
  • Surgical Antisepsis (Surgical Scrub): Follow manufacturer instructions for surgical hard scrub products before donning sterile surgeon's gloves for surgical procedures.

Chapter 7: Infection Control: Clinical Procedures

• Infection Control

• Main Objectives:
• Reduction of available pathogenic microorganisms.
• Elimination of cross-contamination.
• Application of standard and transmission-based precautions.

• General ventilation practices should run continuously, including HEPA filters, bathroom exhaust, patient placement, and scheduling to reduce airborne allergens.

• If contaminated water is directed forcefully into a pocket, microbes can enter the tissue, leading to infections.
• Legionella Bacteria: Biofilm of microorganisms can form on the inside of water lines.
• Recommended Practices:
• Run water lines for 2 minutes at the start of the day
• Run lines for 30 seconds between patients to prevent microbial formation.

• Sterilization and disinfection of patient care items can be categorized into three groups:

1. Critical Items: Come into contact with soft tissue and bone; have the highest risk of disease transmission (e.g., surgical instruments, scalers, probes, needles).
2. Semi-Critical Items: Come into contact with intact mucous membranes; lower risk; should be disposable or sterilized (e.g., mouth mirrors, impression trays).
3. Non-Critical Items: Items that may contact intact skin, posing the lowest risk (e.g., blood pressure cuffs, external probes).

• Include surfaces such as walls, bathrooms, and floors, which pose no direct risk of disease transmission.
• Important considerations include:
• Floors
• Sinks
• Waste disposal (wide opening, lined, covered containers, separate sharps container, and biohazard receptacle).

• Instrument Cleaning and Decontamination: Utilize thermal disinfectors or ultrasonic cleaning processes.
• Instrument Packaging and Management: Seal and sterilize instruments, store packages appropriately to maintain sterility.

• Approved methods include:
• Steam under pressure (autoclave)
• Dry heat
• Chemical vapor
• Immediate-use steam (flash)
• Chemical (cold) sterilization

• Positioning

  • Neutral working position (NWP), considering the interdependence of patient and clinician positioning.
  • Recall that the position of the patient is relatively short compared to that of the clinician.

• General Patient Positions

  • Upright (A)
  • Semi-upright (B)
  • Supine (C)
  • Trendelenburg (D)

• Dental Light Positioning

• Neutral Working Position

  • Back: Neutral alignment with natural spinal curves.
  • Head: On top of spine with forward neck inflection of 15-20 degrees or less.
  • Eyes: Directed downward.
  • Shoulders: Relaxed and parallel to hips.
  • Elbows: Close to body.
  • Forearms: Parallel with floor.
  • Wrist: Forearm and wrist should be in a straight line.
  • Hips: Slightly higher than knees.
  • Thighs: Full body weight distributed evenly on seat.
  • Knees: Slightly apart.
  • Feet: Flat on the floor.

• Clock Positions

  • Right Handed Clinician: Clock positions from 8-1 o'clock.
  • Left Handed Clinician: Clock positions from 11-4 o'clock.