Page-by-page study notes: Wilkins Ch. 7 Infection Control (Clinical Procedures)

Page 1

• Topic: Wilkins Ch. 7 Infection Control – Clinical Procedures
• Focus: PART 1 – Preparing the Operatory
• Goals introduced (overall): reduce pathogenic microorganisms, break the chain of cross-contamination, and apply standard/universal precautions.

Page 2

• Reduction of pathogenic microorganisms: reduce to a level that the body’s resistance mechanisms can handle.
• Break the chain of cross-contamination: prevent transmission between sources, objects, and people.
• Standard precautions: also referred to as Universal Precautions.

Page 3

• Ventilation fundamentals:
  • Vents should be free from clutter.
  • Air flow should go from clean to less clean.
  • Change and maintain filters regularly.
  • Vents cleaned and maintained.
  • Run ventilation continuously during business hours and for 2 hours after closing.

Page 4

• Ventilation enhancements:
  • Portable HEPA filter placed near the patient, away from the clinician.
  • Upper-room ultraviolet germicidal irradiation (UVGI) units can be used with ventilation units to inactivate microbes.
  • Bathroom exhaust fan should run continuously to promote airflow and dilution.

Page 5

• Patient placement strategies:
  • Individual treatment rooms are best; open floor plans are less ideal for infection control.
  • Position patients 6 ft apart when possible.
  • Use physical barriers between patient chairs.
  • Place patients parallel to the direction of air flow when possible.
  • Position patient heads near air return vents when possible.
  • When feasible, position patients’ heads away from open hallways, especially during aerosol-generating procedures.

Page 6

• Preprocedural measures:
  • Have patient rinse with an antiseptic preprocedural rinse, especially before injections and scaling.
  • Have patient brush; 0.2% chlorhexidine rinse provides lower bacterial counts for >60 minutes.

Page 7

• Definition:
  • “The spread of microorganisms from one source to another.”
  • Examples include: patient saliva to a dental instrument to Hygienist’s hand when gloves are not used or gloves/hand hygiene fail.

Page 8

• Definitions:
  • Disinfect: To destroy pathogenic microorganisms (mo's).
  • Sterile: Free from viable microorganisms.

Page 9

• Decontaminate: Use physical or chemical means to remove, inactivate, or destroy pathogenic microorganisms on a surface or item so they are no longer capable of transmitting disease; render safe for handling.
• Disinfectant: An agent (chemical or sometimes physical such as x-rays or ultraviolet light) that destroys microorganisms but may not kill bacterial spores.

Page 10

• Sterilization: Process by which all forms of life, including bacterial spores, are destroyed by physical or chemical means.

Page 11

• Surfaces and equipment features that are easy to clean:
  • Smooth, uncluttered surfaces.
  • Removable hoses; avoid non-retractable, hard-to-clean hoses.
  • Autoclavable or disposable syringe tips.
  • Hand pieces with anti-retraction valves and autoclavable.
  • Use of barriers where possible.

Page 12

• Treatment room supplies and features (summary list):
  • Clinician's stool: foot controls, easy-clean surface, no seams, barrier cover.
  • Light: autoclavable handle or barrier cover.
  • Sharps disposal: appropriate container.
  • Sink: stainless steel; electronic or foot controls; deep for washing up to elbows.
  • Biohazard waste: foot control; sealable liner.
  • Waste: large opening; heavy-duty liner.
  • Chair: foot controls; easy-clean surface; no seams.
  • Unit: removable hoses, straight (not coiled); easy-clean surfaces; autoclavable handpieces.
  • Floor: smooth, easy to clean, nonabsorbent; no carpeting.
  • Note: Copyright 2013 Wolters Kluwer Health; Lippincott Williams & Wilkins.

Page 13

• Treatment Room Feature 1: Dental Chair
  • Controls foot-operated (or must be covered if not).
  • Surfaces should be seamless and easily cleaned.

Page 14

• Treatment Room Feature 2: Light
  • Foot-activated switches or sensors; if not available, use barriers.
• Page 14 also mentions: “Petion Cane” (likely a stray/placeholder item in the transcription).

Page 15

• Treatment Room Feature 3: Clinician's Stool
  • Smooth surface; foot-operated controls.

Page 16

• [Page 16 appears blank in transcript; no notes to add here]

Page 17

• Additional treatment room features:
  • Foot-operated or sensor-controlled fixtures.
  • Sink should be wide and deep enough for effective hand washing.
  • There should be a separate sink for hand washing and instrument care.

Page 18

• Treatment Room Features continued:
  • Floors: No carpeting.
  • Supplies: All sterilizable or disposable.
  • Waste: Receptacle with large opening; separate sharps container; small biohazardous receptacle.

Page 19

• Visual cue question: What is wrong with this picture? When polishing a patient’s teeth, the splatter zone extends to about 6 feet.

Page 20

• Common issues in treatment rooms:
  • Cluttered countertops.
  • Exposed supplies (gloves, masks).
  • Same sink used for sterilization and hand washing.
  • Same countertop for clean and dirty instruments.
  • Soda in treatment area (implies food/beverages in clinical space).

Page 21

• Disinfecting Surfaces: Topic introduction.

Page 22

• Surfaces requiring disinfection (examples):
  • Dental light handles
  • Chair switches
  • Dental radiograph equipment
  • Chairside computer keyboards
  • Reusable containers of dental materials
  • Drawer handles
  • Faucet handles
  • Countertops
  • Pens
  • Telephones
  • Doorknobs
  • Additional items listed (incomplete text in transcript)

Page 23

• Categorization by biocidal activity:
  • High level: Inactivates spores and all forms of bacteria, fungi, and viruses; may be a disinfectant or sterilant depending on time.

Page 24

• Intermediate level: Inactivates all forms of microorganisms but does not destroy spores.
• Low level: Inactivates vegetative bacteria and certain lipid-type viruses; does not destroy spores, TB bacilli, or nonlipid viruses.

Page 25

• Chemical disinfectants: Uses include environmental surface disinfection and dental lab impressions/prostheses.

Page 26

• Disinfection depends on contact of the solution with surfaces: Items must be cleaned and dried for the agent to work.
• Action of the agent may be altered by foreign matter.

Page 27

• EPA approval and labeling requirements for disinfectants:
  • Tuberculocidal, bactericidal, virucidal, and fungicidal.
  • Label must state: shelf life, use life, reuse life; directions for activation; storage; directions for use; disposal instructions; warnings.

Page 28

• Desired properties of disinfectants:
  • Broad spectrum
  • Fast acting
  • Not affected by physical factors
  • Non-toxic
  • Surface compatibility
  • Residual effect on treated surfaces
  • Easy to use
  • Odorless
  • Economical

Page 29

• Common chemical disinfectants mentioned:
  • Gluteraldehydes: should not be used as a surface disinfectant.
  • Chlorine compounds
  • Iodophors
  • Combination phenolics

Page 30

• High-level disinfectants:
  • Can be used as cold disinfectants.
• Limitations:
  • Caustic to skin
  • Irritating to eyes
  • Corrosive to some metals
  • Items need to be rinsed in sterile water
  • Toxic fumes; therefore not used as a surface disinfectant

Page 31

• Sodium hypochlorite; chlorine dioxide:
  • Use life of 1 day; must be mixed daily.
  • Use distilled water; improves stability.
  • Can harm eyes; corrosive; odor; economical.

Page 32

• Povidone-iodine:
  • Broad spectrum.
  • Can discolor.
  • Mix 1 part iodophor to 213 parts water.
  • Mixture color changes from amber to clear as activity declines.

Page 33

• Combination phenolics:
  • Broad spectrum.
  • Lower concentrations used as surface disinfectants.

Page 34

• Statement-based question: High-level disinfectants inactivate spores and all forms of bacteria, fungi, and viruses (Statement A). Intermediate-level disinfectants inactivate all forms of microorganisms but do not destroy spores (Statement B).
  • Answer format: A) both correct; B) both correct; C) A correct, B incorrect; D) A incorrect, B incorrect. (From transcript: select the correct option—A is correct and B is correct.)

Page 35

• Eyewash station usage: How long should a person use an eyewash station? Answer: $15\,\text{minutes}$

Page 36

• Chemical disinfection vs sterilization:
  • Used only for items that cannot be sterilized.
  • Chemical may disinfect in $10-30\,\text{min}$ but may take $10\,\text{hours}$ to sterilize.

Page 37

• Chemical Sterilants (Immersion):
  • Disadvantages: Cannot verify sterilization; difficult to store instruments; time constraints; BIOCIDE.
  • Chemical sterilant requires the longest time to complete cycle.

Page 38

• Preparation of the Treatment Room – Objectives:
  • Control disease transmission
  • Increase working efficiency
  • Create an atmosphere of cleanliness and orderliness
  • Increase patients’ confidence
  • Maintenance of equipment

Page 39

• Hand hygiene and instrument handling:
  • Hand contacts: Touch only what you need; plan ahead; use paper towel barrier.
  • Sterilize items: Critical and semi-critical items need to be sterilized.

Page 40

• Surface category definitions and examples:
  • Critical: Penetrates soft tissue or bone; sterilize or use disposable. Examples: needles, curettes, explorers, probes.
  • Semicritical: Touch intact mucous membrane and oral fluids; does not penetrate; high-level disinfection when sterilization cannot be used. Examples: radiographic biteblock, ultrasonic headpiece, amalgam condenser, mirror.
  • Noncritical: Do not touch mucous membranes (only contact unbroken epithelium). Cleaning and TB intermediate-level disinfection. Examples: light handles, some x-ray machine parts, safety eyewear.

Page 41

• Disposable items: Use whenever possible.
• Cover items that can be covered.
• Chemical disinfection as a general approach.

Page 42

• Two key actions determine disinfectant effectiveness:
  • Physical rubbing and removal of contaminated material.
  • Chemical inactivation of living microorganisms.

Page 43

• Flushing protocols:
  • Flush lines for 2 minutes at the beginning of the day.
  • Flush for 30 seconds before and 30 seconds after each patient appointment.

Page 44

• BARRIERS! (likely a visual or branding slide)

Page 45

• PART 2: Sterilizing Instruments – LAB 3
• Focus: The sterilization and instrument management portion of universal precautions.

Page 46

• Universal precautions in instrument management:
  • All critical and semi-critical supplies should be sterilizable or capable of being sterile.
  • A planned program for instrument management is essential for safe practice.

Page 47

• Personal protective equipment (PPE) and handling:
  • Clinician should wear heavy utility gloves, mask, safety glasses, and a cover gown.
  • Ideally, instruments should be kept in a cassette with minimal handling.

Page 48

• Instrument cleaning workflow (therm disinfection or ultrasonic):
  • Step: Instrument cleaning (therm Disinfection or Ultrasonic)
  • Rinse and dry
  • Clinical use
  • Package
  • Seal
  • Sterilize
  • Store packages

Page 49

• Pre-cleaning step:
  • Does NOT sterilize; only cleans.
  • Safer than manual cleaning.
  • Benefits: increased efficiency, decreased danger to clinician, improved disinfection effectiveness, fewer aerosols, penetrates into all areas, removes tarnish.

Page 50

• Three basic methods to clean instruments:
  1) Instrument washer / thermal disinfector
  2) Ultrasonic processing
  3) Manual cleaning

Page 51

• Instrument Washer / Thermal Disinfector:
  • Uses high-velocity hot water and a detergent.
  • Higher temperature provides disinfection.
  • Disinfection allows cassettes to be handled during packaging.

Page 52

• Ultrasonic Processing (not a substitute for sterilization):
  • It is a cleaning process, not a sterilization method.
  • Advantages: increased efficiency; reduced danger to clinician.

Page 53

• Ultrasonic Processing procedure:
  • Do not overload the unit.
  • Dismantle instruments.
  • Process for correct amount of time.
  • Drain, rinse, and air dry.

Page 54

• Manual Cleaning procedure:
  • Last resort option.
  • Wear heavy-duty gloves.
  • Dismantle instrument.
  • Use long-handled brush; brush away from body.
  • Rinse thoroughly; air dry.

Page 55

• Basic steps in the recirculation of instruments – Packaging step (Part I):
  • Purpose: Prevent contamination; storage method.
  • (Figure references appear; content suggests packaging step concepts.)

Page 56

• Packaging step 2 – Arrangement:
  • Preset cassettes or trays.
  • Date packages.
  • Clear packaging for easy identification.

Page 57

• Packaging step 3 – Preparation:
  • Use sturdy wrap.
  • Must allow steam or chemical vapor to penetrate.

Page 58

• Seal details:
  • Indicator tape: Do not use pens, paper clips, or other metal fasteners that poke holes in packaging.
  • Use only if the package is self-seal and wrap has built-in indicators.
  • Chemical indicator: Used to seal packages unless wrap has built-in indicators.
  • Change in color indicates temperature has been reached; does not guarantee sterility by itself.

Page 59

• Sterilization methods (approved):
  • Steam under pressure (autoclave)
  • Dry heat
  • Chemical vapor
  • Immediate-use steam sterilization (flash)
  • Chemical (cold) sterilization (not recommended)
  • The chosen method must provide complete destruction of all microorganisms, viruses, and spores.

Page 60

• Tests for Sterilization (three tests):
  • External chemical indicator
  • Internal chemical indicator
  • Biological monitor
  • These tests verify that the sterilizer is functioning properly.

Page 61

• External Chemical Indicator:
  • Used to seal the package and indicate that the autoclave temperature has been reached.

Page 62

• Internal Chemical Indicator:
  • Color change assesses instrument exposure to temperature and steam for the required time.

Page 63

• Biological Monitor:
  • Tests that the autoclave is functioning properly.
  • Weekly testing recommended.
  • Refer to Table 7-2 (p. 109) for complete list in the source.

Page 64

• Sterilization indicators by method:
  • Steam autoclave: Geobacillus stearothermophilus (vials/strips/ampules).
  • Dry heat oven: Bacillus atrophaeus (formerly Bacillus subtilis) strips.
  • Chemical vapor: Geobacillus stearothermophilus strips.
  • Ethylene oxide: Bacillus subtilis strips.

Page 65

• Causes of incomplete sterilization:
  • Inadequate preparation.
  • Misuse of equipment.
  • Inadequate maintenance.

Page 66

• Moist Heat (steam under pressure):
  • Causes coagulation of proteins.
  • Autoclave: may be used for all materials except oils, waxes, and powders that are impervious to steam or cannot be subjected to high temperatures.

Page 67

• Types of Autoclaves:
  • Gravity displacement: self-generated steam forces air out; steam enters to penetrate packages.
  • High-Speed Prevacuum (prevacuum): pump removes air for faster steam penetration; examples include Statim.

Page 68

• Table 6-1 – Methods for Sterilization (summary):
  • Steam under pressure (autoclave): Gravity displacement – Time: $15-30\,\text{min}$; Temperature: $250^{\circ}\mathrm{F} = 121^{\circ}\mathrm{C}$; Pressure: $15\ \text{psi}$.
  • Prevacuum: Time: $3.5-10\,\text{min}$; Temperature: $270^{\circ}\mathrm{F} = 132^{\circ}\mathrm{C}$.
  • Dry heat: Time: $120\,\text{min}$; Temperature: $320^{\circ}\mathrm{F} = 160^{\circ}\mathrm{C}$.
  • Unsaturated chemical vapor: Time: $20\,\text{min}$; Temperature: $270^{\circ}\mathrm{F} = 132^{\circ}\mathrm{C}$; Pressure: $20-40\ \text{psi}$.

Page 69

• Important autoclave note:
  • Temperature must remain $121^{\circ}\mathrm{C}$ at $15\ \text{psi}$ for $15\text{ minutes}$ after reaching proper pressure and temperature.
  • Pack loosely to allow steam to reach all instruments.

Page 70

• Sterilization concept:
  • Sterilization is achieved by heat and moisture (no air).
  • Discharge occurs in a downward direction.
  • Pressure is used to attain the heat, not to sterilize by itself.

Page 71

• Sterilization outcomes and scope:
  • All microorganisms, spores, and viruses are destroyed.
  • A wide variety of materials can be treated.
  • Most economical method uses distilled water.

Page 72

• Moist Heat – Disadvantages:
  • May corrode carbon steel.
  • Not suitable for oils and powders.

Page 73

• Dry heat: Action and intended use:
  • Oxidation of molecules leads to organism death.
  • Static air vs forced air options explained.
  • Primarily used for materials that cannot be safely sterilized with steam (e.g., corroding/rusting items).
  • Useful for oils and powders; small metal instruments in special containers.
  • Typical cycle: $160^{\circ}\mathrm{C} = 320^{\circ}\mathrm{F}$ for $2\ hours$ or $170^{\circ}\mathrm{C} = 340^{\circ}\mathrm{F}$ for $1\ hour$ (time starts after target temp is reached).

Page 74

• Dry heat – Advantages and Disadvantages:
  • Advantages: good for items that cannot withstand steam; less corrosion; suitable for sharp instruments if temp is maintained.
  • Disadvantages: long exposure time; higher temp is crucial; penetration is slow and uneven.

Page 75

• Chemical Vapor (aldehyde-based) sterilization notes:
  • Involves alcohol and formaldehyde vapors under pressure.
  • Used for low-melting plastics, liquids, and heat-sensitive handpieces.

Page 76

• Chemical Vapor continued:
  • Microbial and viral destruction results from permeation of heated formaldehyde and alcohol.
  • Not suitable for materials that can be altered by these chemicals or cannot withstand heat.

Page 77

• Chemical Vapor product/method names (examples):
  • VAPO-STERIL or similar solutions.
  • Operates at around $132^{\circ}\mathrm{C}$ under pressure.

Page 78

• Chemical Vapor advantages:
  • Corrosion and rust-free.
  • Relatively short cycle.
  • Easy operation.

Page 79

• Chemical Vapor disadvantages:
  • Requires adequate ventilation.
  • Slight odor.
  • Refill depends on use; typically every 30 cycles.
  • Packages cannot be tightly wrapped or tightly sealed.

Page 80

• Ethylene oxide (ETO) sterilization:
  • Used in hospitals and larger clinics; most materials sterilizable including plastics and rubber.
  • Low-temperature process; effective for heat-sensitive items.
  • Very long cycle time depending on temperature and concentration.
  • Typical duration: approx. $10-16\text{ hours}$.

Page 81

• [Page 81 appears blank in transcript; no notes to add here]

Page 82

• Ethylene oxide – Advantages:
  • Can sterilize many materials including plastics and rubber.
  • Low temperature operation.

Page 83

• Ethylene oxide – Disadvantages:
  • High equipment cost.
  • Requires good ventilation.
  • Increased time required.
  • Items must be aired out for several hours after sterilization.

Page 84

• Flash Sterilization (Immediate-use steam sterilization):
  • Rapid steam heat sterilization used for unwrapped instruments for immediate use.
  • Shorter sterilization times.
  • Use only when urgent; not recommended for items requiring biological spore test results (e.g., implants).
  • Care: follow manufacturer settings; monitors/indicators should be used and checked each cycle.
  • Items used for immediate use should not be stored.
  • Biologic monitoring is not possible in flash sterilization.
  • Beware of potential contamination during packaging; shelf life may vary by environment (up to 1 year in some cases).

Page 85

• Practical cautions for flash sterilization:
  • Do not store items sterilized in flash mode.
  • Monitor indicators per cycle.

Page 86

• Summary table (reiterating sterilization methods and parameters):
  • Moist Heat – Steam Under Pressure: Gravity displacement – Time $15-30\,\text{min}$; Temp $250\ ^\circ\mathrm{F}$ (121°C); Pressure $15\ \text{psi}$.
  • Moist Heat – Steam Under Pressure: Prevacuum – Time $3.5-10\,\text{min}$; Temp $270\ ^\circ\mathrm{F}$ (132°C).
  • Dry Heat – Time $120\,\text{min}$; Temp $320\ ^\circ\mathrm{F}$ (160°C).
  • Unsaturated Chemical Vapor – Time $20\,\text{min}$; Temp $270\ ^\circ\mathrm{F}$ (132°C); Pressure $20-40\,\text{psi}$.

Page 87

• Packaging and storage specifics:
  • Unpackaged instruments are sterile only momentarily.
  • Packaged items can be stored for several months to 1 year, depending on storage method.

Page 88

• Summary – Standard procedures (patient factors):
  • Comprehensive health history.
  • Preprocedural rinse.
  • Protective eyewear for patients.

Page 89

• Clinical preparation and operations:
  • Run water lines for 2 minutes before procedures.
  • Disinfect environmental surfaces.
  • Apply barriers.
  • Use sterilized instruments.
• Factors for dental team:
  • Use PPEs.
  • Thorough hand hygiene.
  • Do not contaminate or cross-contaminate.

Page 90

• Treatment factors:
  • Hypodermic needles: Safe recapping methods; dispose in puncture-resistant sharps container; dispose of partially used anesthetic carpules.
  • Removal of oral prostheses: Wear gloves to receive prostheses from patient.

Page 91

• Post-treatment procedures:
  • Use heavy puncture-resistant gloves to handle instruments.
  • Disinfect, clean, and prepare instruments for sterilization.
  • Disinfect eyewear/face shield for patient and dental team member.
  • Sterilize instruments.

Page 92

• Cleaning face after exposure:
  • Should occur after an incident and several times a day.
  • Smoking and eating are banned from treatment areas.

Page 93

• After an exposure incident (steps):
  • Immediately wash the wound with soap and water.
  • Report to designated official and complete an incident report as required.
  • Follow clinic/institution procedures and the most recent guidelines by the US Public Health Service.
  • Important note: Do not squeeze the wound to make it bleed.

Page 94

• Final takeaway: “Only YOU can stop the spread of infection!”
• Emphasizes personal responsibility in infection control and adherence to procedures.