In any infection control strategy there are two inherent significant concepts:
The dental health-care workers need to implement a set of risk reducing measures whenever they encounter blood or other body fluids. Therefore, it is recommended that universal precautions are applied to all dental procedures that involve blood and/or blood- contaminated saliva. The concept of universal precautions includes the proper handling of sharp instruments, use of disposable materials and the use of barriers as personal protection. It is based on the principle that medical histories and physical examinations cannot identify all carriers of blood- borne diseases. Therefore, dentist must treat all patients as infective and apply appropriate infection control measures to all patients.
It is important to know that not all dental procedures carry the same risk of disease transmission and hence, may not require the same degree of personal barrier protections. Minimum barriers used in dentistry are gloves, masks, protective eyewear and clinical attire. It should be noted that blood is the most important transmitter of disease in the dental office. Therefore, procedures involving blood, body fluids, saliva and non-intact tissues require maximum protection. On the other hand, procedures involving no or less risk of exposure to blood may not need these barrier precautions.
Thus it is recommended that practitioners should evaluate the dental procedure and the risk of exposure expected for each treatment prior to choosing the appropriate personal barrier precautions for the same.
Additional factors to consider when making decisions about which personal protective barriers to implement include:
The need for personal protective barriers is greater when circumstances of practice are adverse.
Maintaining proper health of the dental practitioner and that of the dental staff members is an important part of infection control. The dental staff consists of the dental practitioners, dental hygienist, patient care members which includes the dental assistants and the non patient care staff which include administrative, housekeeping and laboratory technician.
The objective is to educate the New Practitioners regarding the principles of infection control, identify work- related infection risks, institute preventive measures and ensure prompt exposure management and medical follow- up.
Personnel are more likely to comply with an infection-control programme and exposure- control plan if they understand its rationale. Clearly written policies, procedures and guidelines can help ensure consistency, efficiency and effective coordination of activities. Education and training should be appropriate to deal with the assigned duties of specific diseases (e.g., techniques to prevent cross- contamination or instrument sterilization).
For dental professionals who perform tasks or procedures likely to result in occupational exposure to infectious agents, training should include:-
Inclusion of dental professionals with minimal exposure risks (e.g., administrative employees) in education and training programmes may enhance understanding of infection-control principles and the importance of the programme.
Immunization of the dental team before they are placed at risk of exposure remains the most efficient and effective use of vaccines. Non-patient care staff may also be included in the immunization programme. Immunization will be provided by a pre arranged qualified health care professional or by the dental workers based on the latest recommendations as well as medical history and risk of occupational exposure.
Hepatitis is a major health hazard for members of all health occupations and is a well recognized occupational risk for the dental team. Currently two recombinant DNA hepatitis B vaccines are available in India; Recombivax HB and Engerix- B. Both vaccines are considered to be safe and effective towards producing immunity to HBV. The vaccines are administered as 3 injections at the interval of 0,1,6 months. Members of the dental team receiving the vaccine should be tested for antibody to HBV surface antigen ( HBs Ag) 2 months after completion of the three dose vaccination series. Person who develop a protective antibody response (greater than 10 ml units per ml) after vaccination are considered immune. If there is no antibody response after the second series, a test for HBs Ag should be performed.
Vaccine induced antibodies gradually decline over time and 60% of persons who initially responded to vaccination will lose detectable antibodies over 12 years. However immunity continues to prevent disease. Booster vaccines and periodic serological testing to monitor antibody levels after completion of the vaccine series are not necessary for vaccine responders.
Although transmission of bloodborne pathogens (e.g. HBV, HCV and HIV) in dental health- care settings can have serious consequences, such transmission is rare. Exposure to infected blood can result in transmission from patient to DHCP, from DHCP to patient and from one patient to another. The opportunity for transmission is greatest from patient to DHCP.
Avoiding occupational exposures to blood is the primary way to prevent transmission of HBV, HCV and HIV, to HCP in health-care settings. Exposures occur through percutaneous injury (e.g. a needlestick or cut with a sharp object), as well as through contact between potentially infectious blood, tissues or other body fluids and mucous membranes of the eye, nose, mouth, or nonintact skin (e.g. exposed skin that is chapped, abraded or shows signs of dermatitis).
Precautions Include :-
Dental practitioners are responsible for monitoring their own health status. DHCP who have acute or chronic medical conditions that render them susceptible to opportunistic infection should discuss with their personal physicians or other qualified authority whether the condition might affect their ability to safely perform their duties.
However, it might be necessary for the dental practitioner to refrain from work or patient contact to prevent further transmission of infection. Use of latex gloves among the dentists has increased markedly, but this has resulted in allergic reactions to natural rubber latex among dental professionals and patients, as well as reports of irritant and allergic contact dermatitis from frequent and repeated use of hand- hygiene products, exposure to chemicals and glove use.
The health status of the dental practitioners can be monitored by maintaining records of work- related medical evaluations, screening tests, immunizations, exposures and post exposure management.
It is required that the employers ensure that certain information contained in employee medical records is kept confidential and not disclosed or reported without the employee's written consent to any person within or outside the workplace.
PPEs are designed to protect the skin and the mucous membranes of the eyes, nose and mouth of dental practitioners from exposure to blood or other infectious materials.This is mandatory in specified circumstances.
Use of rotary dental and surgical instruments (e.g. hand-pieces or ultrasonic scalers) and air- water syringes creates a visible spray that contains primarily large- particle droplets of water, saliva, blood, microorganisms and other debris.This spatter travels only a short distance and settles down quickly, landing on the floor, nearby operatory surfaces, dental practitioners or the patient. The spray also might contain certain aerosols (i.e. particles of respirable size, < 10 µm) may remain airborne for extended periods and can be inhaled.
General work clothes (e.g. uniforms, scrubs, pants and shirts) are neither intended to protect against a hazard nor considered PPE).
A surgical mask that covers both the nose and mouth, protective eyewear with solid side shields or a face shield should be worn by dental practitioners during procedures and patient- care activities.
A surgical mask protects against microorganisms generated by the wearer, with >95% bacterial filtration efficiency and also protects dental professionals from large-particle droplet spatter that might contain blood borne pathogens or other infectious microorganisms. If the mask becomes wet, it should be changed between patients or even during patient treatment.
Protective clothing and equipment (e.g. gowns, lab coats, gloves, masks and protective eyewear or face shield) should be worn to prevent contamination of street clothing and to protect the skin of dental professionals. Protective clothing including aprons, lab coats, clinic jackets or similar outer garments may be reusable or disposable.
The sleeves of the protective clothing should be long enough when the gown is worn so as to protect the forearms (i.e. when spatter and spray of blood, saliva or OPIM to the forearms is anticipated). Dental professionals should change protective clothing when it becomes visibly soiled and as soon as feasible if penetrated by blood or other potentially infectious fluids. After removal it should be placed in laundry bags or in containers that are properly marked. All protective clothing should be removed before leaving the work area.
Gloves must be worn whenever you anticipate contact with blood, saliva, mucous membranes, blood contaminated objects or surfaces. The risk of disease transmission to both dental professionals and patients increases when gloves are not used. The dental professionals acquire HBV from their patients if the hands are ungloved.
It is recommend that dentists wear protective gloves for all operative procedures. The recommendation for glove wearing has been made to protect both the operator and the patient from cross-infection. The routine use of gloves protects the dental team from blood borne viruses such as Hepatitis B, C and HIV.
Occupationally related contact dermatitis can develop from frequent and repeated use of hand hygiene products, exposure to chemicals and glove use. Allergic contact dermatitis often manifests as a rash beginning hours after contact and similar to irritant dermatitis. It is usually confined to the area of contact. Latex allergy (type I hypersensitivity to latex proteins) can be a more serious systemic allergic reaction, usually beginning within minutes of exposure but sometimes occurring hours later and producing varied symptoms.
More common symptoms include: runny nose, sneezing, itchy eyes, scratchy throat, hives and itchy burning skin sensations. More severe symptoms include: asthma marked by difficulty in breathing, coughing spells and wheezing; cardiovascular and gastrointestinal ailments and in rare cases, anaphylaxis and death.
The following precautions should be considered to ensure safe treatment for dental professionals who have possible or documented latex allergy:
The following precautions should be considered to ensure safe treatment for patients
Hands should be thoroughly washed using an antimicrobial soap solution. This reduces the resident and transient micro- organisms which are capable of transmitting disease.
The preferred method for hand hygiene depends on :