ASSIGNMENT Write a step by step clinical protocol for daily infection control, which you would advocate in your

own dental practice

This assignment consolidates recommendation for preventing and controlling infectious diseases and managing dental healthcare personnels health and safety concerns related to infection control in my dental clinic. This assignment is done under the following scope : Personal Protective Equipments (PPE) Hand washing Waste management Management of needle prick Blood spillage Management of extracted teeth

INTRODUCTION
Definition of Infection The entry and development or multiplication of an infectious agent in the body of humans or animals. The body respond in the same way to defend itself against the invader such as : Commensal Pathogenic bacteria Virus Parasite Fungi

Modes of transmission 1) Direct Transmission Direct contact Droplet infection Contact with soil Inoculation into skin or mucosa Transplacental 2) Indirect Transmission Vehicle borne Vector borne Air borne Fomite borne Unclean hands and fingers

GUIDELINES
Below are the guidelines for infection control that I would follow in my clinic I. II. III. Application of standard precautions rather than universal precautions Work restrictions for healthcare personnel (HCP) infected with or occupationally exposed to infectious diseases Management of occupational exposures to blood borne pathogens, including PEP for work exposures to hepatitis B virus (HBV), hepatitis C virus (HCV) and human Immunodeficiency virus (HIV) Selection and use of devices with features designed to prevent sharp injury Hand hygiene products and surgical hand asepsis Contact dermatitis and latex allergy Sterlization of unwrapped instruments Dental water quality concerns Dental radiology Aseptic technique for parentral medications Pre-procedural mouth rinsing for patients Oral surgical procedures Laser and electro surgery plumes Tuberculosis Prion related diseases Infection control programme evaluation

IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI.

Personal Protective Equipments (PPE)

Protective clothings, helmets, goggles or other garments designed to protect the wearers body from injury by blunt impacts, electrical hazards, heat, chemical and infection. The primary PPE which will be used in my clinic would be :

Masks Protective eyewear Face shields Protective clothing (surgical gowns) Gloves Head caps Carpeting and cloth furnishings

These will prevent direct and indirect contact with the debris, sprays and splashes which may carry blood borne viruses which gain entry into the blood stream of both operator and assistant in the clinic.
a) Surgical Mask i. Covers both the nose and the mouth of the operator and assistant with > 95% of bacterial filtration efficiency ii. Changed after a maximum of one hour of continuous use or after each patient iii. The same mask should not be worn for two different patients iv. Certified particulate filter respirator should be used eg. N95, N99, N100.

b)

Protective eyewear i. Shields the eyes from spatter and debris during dental procedures ii. It must be cleaned with soap and water and disinfected with disinfectant after each patient iii. Used for both healthcare personnels and patients to protect from contaminants such as blood, saliva, chemical and others

c) Face shield i. Protects the whole face from spatter and debris ii. Must be disinfected with disinfectant after each patient to prevent contamination to ensure a safe, infection free environment

d) Protective Clothing i. Should be worn to prevent contamination of street clothing and to protect skin of the healthcare personnels from exposures to bloody and body substances ii. The protective clothings are surgical gowns, labcoats iii. When it is visibly soiled and penetrated by blood and potentially infectious fluid, it should be changed immediately iv. Contaminated clothing should be soaked in a disinfectant before washing with detergent and water 5

v.

Requirements of appropriate protective clothing are as follow :o Minimizing the amount of uncovered skin and street clothing o Design which allow the cuff to be tucked into the gloves o Have a well-sealed closure o Provide effective barrier against bacteria even when it is wet o Can be removed immediately upon leaving the working area

e) Gloves i. Gloves shall be worn when it can be reasonably anticipated the healthcare worker may have hand contact with blood, semen, vaginal secretions, urine, feaces, saliva, sputum, vomitus, or any body substance. ii. Should be worn when examining and treating patients iii. Gloves must be discarded when there is visible puncture to prevent contamination iv. Medical gloves, both patient examination and surgical gloves , are manufactured as single use, disposable items v. Gloves must be discarded and replaced for each patients vi. If cross-contamination of surfaces and equipment is anticipated, one hand should remain ungloved and not be used to perform the exam. vii. Change gloves between patient contacts.Gloves should not be washed or disinfected for continued use. Gloves should not be reused. viii. Glove liners, bandages, gauze, or finger cots can help minimize hand irritations. ix. Sterile gloves minimize transmission of microorganisms from the hands of surgical DHCP to patients x. Double gloving is introduced and believed to provide additional protection from occupational blood contact during surgical procedures xi. DHCP should use the correct size gloves

Sequence for donning PPE

1. 2. 3. 4. 5. Perform hand hygiene Gown (if applicable) Mask Eyewear Gloves (if applicable)

1. How to don a gown Opening is in the back Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back Secure at neck and waist If gown is too small, use two gowns: the first ties in front, the second ties in back 2. How to don a mask secure on head with ear loops Place over nose, mouth, and chin Fit flexible nose piece over bridge Adjust fit snug to face and below chin 3. How to don eye protection Position eyewear over eyes and secure to head using ear pieces 4. How to don gloves Don gloves last Insert hands into gloves Extend gloves over gown cuffs (if wearing gown) 5. How to use gloved hands Keep gloved hands away from face Avoid touching or adjusting other PPE
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Remove gloves if they become torn; perform hand hygiene before donning new gloves Limit surfaces and items touched

Sequence for removing PPE All items must be removed and discarded carefully Perform hand hygiene after gloves/gown removal before your hands go near your face
(for removal of masks and eye protection) and after completion of PPE removal, and any time you suspect your hands are contaminated during PPE removal. 1. Glove removal Outside of glove is dirty; use glove-to-glove/skin-to-skin handling method Grasp outside edge near wrist Peel away from hand, turning glove inside out Hold in opposite gloved hand Slide ungloved finger under wrist of remaining glove Peel off from inside, creating a bag for both gloves Discard 2. Gown removal Gown front and sleeves are dirty; handle by inside/back of gown Unfasten ties Peel gown away from neck and shoulder Turn contaminated outside surface toward the inside Fold or roll into a bundle Discard 3. Perform hand hygiene 4. Eyewear removal Outside of eyepiece is dirty; handle by earpieces Grasp earpieces with ungloved hands Pull away from face Place in designated receptacle for reprocessing 5. Mask removal Front of mask is dirty; handle by ear-loops Remove from face, in a downward direction, using ear-loops Discard 6. Perform hand hygiene immediately after removing PPE.

HAND HYGIENE
General term which applies to : Hand washing Antiseptic hand wash Antiseptic hand rub Surgical hand antisepsis

Simple and the most important practice to reduce the transmission of infectious agents in the clinic. The preferred method for hand hygiene depends on the type of procedure, the degree of contamination and the desired persistence of antimicrobial action on the skin. Hand hygiene should be advocated : Pre and post direct contact with patients After contamination with bodily fluids or blood When gloves are torn accidentally Before a start and end of a procedure Before undertaking invasive procedure on patients If moving a contaminated body site to a clean body site during patient care

The antiseptic agent should be : Substantially reduce microorganisms on intact skin Contain a non-irritating antimicrobial preparation Broad spectrum antimicrobial activity Fast acting Persistent effect

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Antiseptic Handwash Aqueous antiseptic handwash is used to remove organic contamination and repeated use maintain low bacterial handcounts. This is recommended prior to an aseptic technique. Allergy can develop to these disinfectants, although the most common reason for allergy' is inadequate drying of the hands. Hand creams should only be applied at the end of the shift. Some users are genuinely allergic to chlorhexidine and alternatives (e.g. povidone iodine) may be used. If bar soap is recommended, it should be supplemented with an alcohol rub prior to carrying out an antiseptic procedure.

Chlorhexidine Studies have indicated that chlorhexidine handwash is more effective than povidone iodine. The recommended antiseptic handwash is 2-4% chlorhexidine gluconate with 4% isopropyl alcohol in a detergent solution of pH S.U-8.5. Povidone iodine Products containing 7.5% to 10% povidone iodine in a surgical handscrub should be used. Scrub hands in two consecutive 3 minutes duration. Alcohol-based disinfectants (alcohol rub)-Ethyl alcohol, isopropyl alcohol Alcohol based disinfectants are extremely useful and are excellent means of providing hand disinfection in areas where washing facilities are lacking.

Other aspects of hand hygiene i. ii. Do not wear artificial fingernails or extenders while in direct contact with patients Ensure short fingernails all the time (Tips lesser than 0.5 cm)

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STERILIZATION AND DISINFECTION OF PATIENT CARE ITEMS

Sterilization Destruction of all living organisms, including highly resistant bacteria spores Ensures destruction of all organisms transferred to an item during use on one patient before reuse of the item on a subsequent patient

Instrument Classification i. Critical Instruments o Penetrate soft tissues or bone o Sterilized (heat) in between each use o Discarded if possible o E.g. Periodontal probe, explorer, root planning instruments and ultrasonic scalers Semi-critical o Not intended to penetrate soft tissues or bone o High level disinfectants are indicated for instruments that cannot be heat sterilized o Chemical germicides are not as reliable as heat sterilization o E.g. Mouth morrors, ultrasonic scaling handpieces, impression trays and oral photography retractors Non-critical instruments o Come into contact only with intact skin o Disinfect with EPA registered low to intermediate level disinfectant o E.g. X-ray head, light handles, high and low volume evacuators, instruments trays, chair surfaces

ii.

iii.

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Methods commonly used in the dental clinics: 1. Steam sterilisation 2. Dry heat 3. High level disinfection by: Soaking in chemicals Boiling 4. Low to Medium level disinfection 1. STEAM STERILISATION o Steam sterilisation (autoclaving) is the recommended method for reusable dental instruments. The autoclave should be operated according to the manufacturer's recommendations. o All autoclaves must be tested for efficacy fortnightly by the use of biological indicators to ensure that the contents of the load have been subjected to sterilisation conditions.

2. DRY HEAT o Sterilisation by dry heat in an electric oven is an appropriate method for instruments that can withstand high temperature of 170C or 340F. o It should be used according to manufacturer's recommendation.

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3. HIGH-LEVEL DISINFECTION o High-level disinfection by soaking in chemicals Immersion of dental instruments in a chemical disinfectant for a specific period of time has been shown to confer high level disinfection. For chemical disinfectants to be reliable the following should be adhered. The disinfectant solution should be properly prepared according to the manufacturer's instructions Instruments must be soaked for the specified period of time All instruments should be free of debris prior to soaking There should be sufficient v1o1l ume of the solution to ensure that all the instruments are totally immersed. Prior to use or storage, the instruments should be thoroughly rinsed with water. Discard disinfectant solution in accordance with the manufacturer's instructions. Solution used is gluteraldehyde @ gluteraldehyde 2%. A commonly used high level disinfectant is Gluteraldehyde. Gluteraldehyde is usually available as a 2% aqueous solution that needs to be activated before use. Activation involves addition of a powder or a liquid buffer supplied with the solution; this renders the solution alkaline. They give off a toxic, irritant vapour which operators should avoid. Skin contact with the liquid should also be avoided.

o High-level disinfection by boiling A high level of disinfection is achieved when instruments are boiled for 20 minutes. This is a simple method for inactivating most pathogenic microbes when sterilisation equipment is not available. To achieve high level disinfection: Boiling should be at 100C for at least 20 minutes Instruments should not be added during the boiling cycle

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4. LOW TO MEDIUM LEVEL DISINFECTION o Sodium hypochlorite Sodium hypochlorite solutions (e.g., liquid bleach), are excellent immediate to low-level disinfectants. They are bactericidal, virucidal, inexpensive and widely available. Concentrations ranging from 5000 ppm (1:10 dilution) to 500 ppm (1:100 dilution) are effective depending on the amount of organic material present. However, they have two important disadvantages. They are corrosive. They will corrode nickel and chromium steel, iron and other oxidizable metals. Contact should not exceed 30 minutes. Dilutions should not be prepared in metallic containers as they may corrode rapidly. They deteriorate. Solutions should be recently manufactured and protected in storage from heat and light. Dilutions should be prepared just before use.

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WASTE MANAGEMENT Waste management is the collection or disposal of waste material in proper manner in order to reduce their effect on health, environment and esthetics. The management involve wast material in the form of :a. b. c. d. Solid Liquid Gaseous Radioactive substances

CATEGORIES OF WASTE

Infectious waste Lab cultures, equipments Pathological waste Body parts, tissue Sharps Needles, blade Pharmaceutical waste Expired drugs Genotoxic waste Cytotoxic drugs, vomit, urine
Chemical waste Lab reagent, solvents, disinfectants Waste with high content of metal Mercury Pressurized containers Gas cylinder, aerosol cans Radioactive waste Unused fixer and developer solution

Clinical wastes are wastes containing: Human or animal tissue Blood or body fluids Excretions Drugs Pharmaceutical products Soiled swabs or dressings Syringes, needles, sharps Any waste that has come into contact or been mixed with any of the above types of wastes Waste unless rendered safe may prove hazardous to any person coming into contact with it.
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DESCRIPTION 1. Blood an body fluid waste o Soiled surgical dressings, e.g. cotton wool, gloves, swabs. All contaminated waste from treatment area. Plasters, bandages which have come into contact with blood or wounds, cloths and wiping materials used to clear up body fluids and spills of blood o Material other than reusable linen, from cases of infectious diseases (e.g. human biopsy materials, blood, urine, stools) o Pathological waste including all human tissues (whether infected or not) 2. Waste posing the risk of injury (sharps) o All objects and materials which are closely linked with healthcare activities and pose a potential risk of injury and/ infection, e.g. needles, scalpel blades, blades and saw, any other instruments that could cause a cut or puncture 3. Infectious wastes o Clinical waste arising from laboratories (e.g. pathology, haematology, blood transfusion, microbiology, histology) 4. Pharmaceutical and Cytotoxic Pharmaceutical Wastes o Pharmaceuticals which have become unusable for the following reasons: expiry date exceeded expiry date exceeded after the packaging has been re-opened or the ready to use preparation prepared by the user use is not possible for other reasons (e.g. call back)

WASTE MANAGEMENT GUIDANCE Special requirement on the management from the viewpoint of infection prevention. These categories of waste must always be incinerated completely in an appropriate incinerator.

Collected and managed separately from other waste. The collection container; must be puncture resistant and leak tight. This category of waste has to be disposed/destroyed completely as to prevent potential risk of injury / infection

Special requirement on the management from the view point of infection prevention This category of waste must always be incinerated completely in an appropriate incinerator o Class I - pharmaceuticals such as camomile tea, cough syrup and the like which pose no hazard during collection, intermediate storage and waste management managed jointly with municipal wastes o Class II - pharmaceuticals which pose a potential hazard when used improperly by unauthorised persons: managed in an appropriate waste disposal facility o Class III - Heavy metal- containing unidentifiable pharmaceuticals:
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o Wastes arising in the use, manufacture and preparation of and in the oncological treatment of patients with, pharmaceuticals with a cytotoxic effect (mutagenic, carcinogenic and teratogenic properties)

managed in an appropriate waste disposal facility. Intermediate storage of these wastes takes place under controlled and locked conditions. For reasons of occupational safety, cytotoxic pharmaceutical wastes must be collected separately from pharmaceutical waste and disposed of in a hazardous waste incineration plant.

WASTE SEGREGATION All healthcare establishments in Malaysia shall adopt the following standard colour coding which is widely accepted:Black : General wastes Yellow : Clinical wastes for incineration only Light blue : Wastes for autoclaving or equivalent treatment

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HANDLING, STORAGE AND INTERNAL TRANSPORTATION

I. At all times where manual handling of yellow clinical waste bags is required, the necks of the bags should be positioned to allow access for further movement of the bags when necessary. Manual handling of waste bags should be minimized wherever possible. All clinical waste bags should be handled by the neck only. Specific areas for the initial storage of clinical wastes, in the wards and departments shall be made available and located adjacent to the source of the waste. The bags and containers containing clinical wastes from the initial storage area shall be removed regularly. Double yellow bags shall be used for clinical wastes from high risk areas such as infectious disease and isolation nursing units and for heavy clinical wastes such as human tissues. Syringes with attached needles shall be discarded into sharps Containers as one unit. Internal transport routes (from wards / departments to central storage area) shall be designed to minimize the passage of waste through patient care areas and other clean areas. Dedicated wheeled containers, trolleys or carts shall be used to transport thewaste containers to the main storage area. These vehicles shall be reserved only for the transportation of clinical waste.They should be thoroughly cleaned and disinfected immediately following any spillage or accidental discharge Wheeled containers, trolleys or carts for transferring clinical wastes within hospitals shall be designed and constructed so that:o The surfaces of the wheeled containers, trolleys or carts are smooth and impermeable o They do not offer harbourage to insects and vermin o Particles of waste are not easily trapped on edges or crevices o They should contain any leakage from damaged containers o They can easily be cleaned, disinfected and drained o The waste may be easily loaded, secured and unloaded.

II. III.

IV.

V. VI.

VII.

VIII.

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STORAGE Wastes should be stored in separate area, room or building There should be water supply for cleaning purposes Should allow easy access Should be protected from the sun Should be in inaccessible for animals, insects and birds Not located near food sources

TRANSPORTATION OF CLINICAL WASTE The transportation of clinical waste from a central storage area to an approved facility requires the use of dedicated vehicles The vehicle shall be thoroughly cleaned and disinfected immediately following any internal spillage. The cleaning should be carried out on a proper surfaced area with the drainage running to the foul sewer.

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MANAGEMENT OF SPILLAGE FROM CLINICAL WASTE BINS

Wear heavy duty gloves

Place damaged bag into second yellow bag

Collect spilled contents and place into the second bag

Avoid contaminating the outside surface of the second bag

Secure second bag in usual

If appropriate, clean the contaminated surface and leave

Discard or disinfect the heavy duty gloves and wasg the hand thoroughly

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MANAGEMENT OF NEEDLE PRICK INJURY

Needle prick injury is one of the commonly occurring injury in the clinic. Average risk following percutaneous exposure to HIV-infected blood in healthcare settings is about 3 per 1000 injuries, less than 1:1000 following mucocutaneous exposure and has never been recorded following contact of HIV blood with intact skin

Preventive measures o Wash hands before and after contact with each patient and before donning and removal of gloves o Change gloves between patients o Cover with waterproof dressings any existing wounds, skin lesions and all breaks in exposed skin and wear gloves if hands are extensively affected o Wear gloves where contact with blood can be anticipated o Avoid usage of sharp instruments whenever possible, and if essential, exercise particular care in handling and disposal o Avoid open footwear in situation where blood may spill or when sharp instruments and needles are handled o Clear up spillage of blood promptly and disinfect surfaces o Wear gloves when cleaning equipment prior to sterilization or disinfection, when handling chemical disinfectant and when cleaning up spillages o Follow safe procedures for disposal of contaminated wastes

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FLOW CHART SHOWING THE MANAGEMENT OF NEEDLE PRICK INJURY

Injury

Allow wound to bleed, do not scrub

Wash thoroughly in running water and cover with a water proof plaster

Assess Hep.B antibody status of victim and establish viral carriage status source patient

Refer to infectious disease physician/consultant/microbiologist

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MANAGEMENT OF OCCUPATIONAL BLOOD EXPOSURES I.

Provide immediate care to the exposure site Wash wounds and skin with soap and water Flush mucous membranes with water Determine risk associated with exposure Type of fluid (e.g. blood, saliva, infectious fluid or tissue) Type of exposure (e.g. percutaneous injury, mucous membrane or non intact skin exposure, bites resulting in blood exposure) Evaluate exposure source Assess the risk of infection using available information Test known sources for HBsAg, anti-HCV and HIV antibody)consider using rapid testing) For unknown sources, assess risk of exposure to HBV, HCV or HIV infection Do not test discarded needles or syringes for virus contamination Evaluate the exposed person Assess the immune status for HBV infection (i.e. by history of hepatitis B vaccination and vaccine response) Further treatment

II.

III.

IV.

V.

The exposed person is then referred to physician/consultant/microbiologist for

further treatment

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MANAGEMENT OF HUMAN BLOOD SPILLAGE

a) Cleaning and disinfection strategies for blood spills o Blood contamination events occurs during dental procedures using rotary or ultrasonic instrumentation o Blood spill or either clinical contact or housekeeping surfaces should be contained and managed as quickly as possible to reduce the risk of contact by patients and DHCP o The person who cleans should wear gloves and other PPE as needed o Visible organic material should be removed with absorbent material o Non porous surfaces should be cleaned and decontaminated with ether EPA- registered hospital disinfectant effective against HBV and HIV EPA-registered hospital disinfectant with tuberculoid claim b) Discharging blood or other body fluids to sanitary sewer or septic tanks o All containers with blood or saliva can be inactivated in accordance with stateapproved treatment technologies or the contents can be carefully poured down a utility sink, drain or toilet o Appropriate PPE should be worn when performing this task o Multiple blood borne pathogens, particularly viruses, are not stable in the environment for long periods and the discharge of limited quantities of blood and other bodily fluids into the sanitary sewer is considered as a safe method for disposing these waste materials

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FLOW CHART OF HUMAN BLOOD SPILL CLEANUP PROCEDURE

Put on gloves with appropriate PPE

Remove any broken glass or sharp objects by means of forceps, broom and dust pan. Never remove sharp/broken glass by hands

Contain the spill by covering with paper towels and carefully pour appropriate disinfectant solution around the spill. Take care not to splash disinfectant solution while pouring

Remove the paper towels and repeat the process until all visual soilage is removed

Re-wet the cleaned area with disinfectant and air dry or let stand for 10 minutes before wiping dry

Place all contaminated paper towels in the clinical waste bin and dispose as usual

Remove all PPE and immediately wash hands

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MANAGEMENT OF EXTRACTED TOOTH

1. Disposal Discarded extracted teeth are subjected to containerization and labelling provisions outlined by OSHAs blood borne pathogens standard Infectious material (extracted teeth) should be disposed in medical waste containers Extracted teeth to be sent to dental laboratory should be cleaned, surface disinfectant with disinfectant with intermediate-level activity Extracted teeth with amalgam should not be placed in medical waste container that uses incineration for final disposal Send to commercial metal recycling State and local regulations should be consulted regarding disposal of the amalgam 2. Educational Setting Extracted teeth are occasionally collected for use in per-clinical education training Should be cleaned of visible blood and gross debris Maintained in a hydrated state in a well-closed container, abelled biohazard symbol Autoclaved with the most economical storage solution Heat sterilization - allow safe handling If extracted teeth contain amalgam, immerse in 10% formalin solution for two weeks Use of teeth without amalgam is more preferred safety autoclave

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CONCLUSION The increase in the number of transmissible diseases has led to global concern and has affected the way dentistry is practiced. Dentistry is involved in treatment that includes contact with blood, mucosa or blood-contaminated body fluids, including saliva. It is essential to use proper universal precautions such as treatment gloves, masks, protective eye wear, over garments, plastic barriers to protect equipments, proper use of disinfectants and sterilization to prevent cross infection. These measures can prevent the spread of diseases from one patient to another and can also stop transmission from patient to dentist and vice-versa. The dental clinic must not act as a point for spread of diseases. There have been numerous instances of spread of diseases like Hepatitis B from patient to patient via dental clinics. Some of the highly infectious diseases like Hepatitis B, Hepatitis C, and HIV can stopped from transmission by using proper infection control measures. Immunization for Hepatitis B, A and regular blood tests for HIV and Hepatitis antibodies is also important for dental health care workers. Dentists must implement engineering controls to reduce production of contaminated spatter, mists and aerosols. Safe handling of contaminated needles and other sharp items, along with proper disposal, is essential. Infection control measures to be undertaken in the presence of an exposure must be trained to all staff. Every practice must have its own infection control policy. Proper management of dental waste must also be undertaken to prevent contamination of water and food. Proper precautions while handling needles and sharp object must be undertaken to prevent accidents

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