Infection Control Components

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.

1. Surgery, periodontal procedures, etc may result in exposure to blood, blood- contaminated saliva or non-intact tissue, especially when aerosolization or splatter is likely to occur. Hence the personal barrier precautions are necessary.
2. Examinations, radiographs, etc may result in contact with intact oral mucosa but no anticipated blood, aerosolization or splatter. Hence the personal barrier precautions are of moderate necessity (gloves recommended, masks and eyewear optional).
3. Consultations, etc. may not result in exposure to blood, body fluids or tissues. Hence the personal barrier precautions are of minimum necessity.

Additional factors to consider when making decisions about which personal protective barriers to implement include:

• Immunization and the health status of the dentist.
• Hazards inherent in the procedure itself.
• Dentist's skin.
• Skill of the dentist.
• Patient's co-operativeness.
• Medical history of the patient.
• Type of practice situation.
• Physical setting e.g. crowded room.

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.

Education and Training

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:-

1. Description of their exposure risks.
2. Review prevention strategies and infection-control policies and procedures.
3. Discussion regarding how to manage work- related illness and injuries, including post exposure prophylaxis.
4. Review of restrictions for minimizing exposure or infection.

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 Programmes

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.

• Immunizations substantially reduce both, the number of dental professionals susceptible to these diseases and the potential for disease transmission to other dental professionals and patients.
• The dental health care professionals are considered to be at substantial risk for acquiring or transmitting Hepatitis B, influenza, measles, mumps, rubella and varicella. All of these diseases are vaccine- preventable.
• Hepatitis B vaccination, serologic testing, follow-up and booster dosing should be monitored.
• Counsel all non responders to vaccination who are HBs Ag negative regarding their susceptibility to HBV infection and precautions to be taken.
• Provide employees appropriate education regarding the risks of HBV transmission and the availability of the vaccine. Employees who decline the vaccination should sign a declaration form to be kept on records.
• IDA recommends that all dental professionals be vaccinated or have documented immunity to these diseases.

Preventing Transmission to Blood Borne Pathogens

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.

Exposure Prevention Methods

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 :-

• Use of PPE (e.g. gloves, masks, protective eyewear or face shield and gowns) intended to prevent skin and mucous membrane exposures.
• Consider sharp items (e.g. needles, scalers, burs, lab knives and wires) that are contaminated with patient blood and saliva as potentially infective and establish engineering controls and work practices to prevent injuries.
• Other protective equipment (e.g. finger guards while suturing) might also reduce injuries during dental procedures.
• Work-practice controls which include responsibilities like handling, using, assembling or processing sharp devices (e.g. needles, scalers, laboratory utility knives, burs, explorers and endodontic files) or sharps disposal containers.
• Work-practice controls can include removing burs before disassembling the handpiece from the dental unit, restricting use of fingers in tissue retraction or palpation during suturing and administration of anesthesia, and minimizing potentially uncontrolled movements of such instruments as scalpel or laboratory knives.
• Offer the HBV vaccination series to all DHCP with potential occupational exposure to blood or other potentially infectious material.
• Identify, evaluate and consider devices with engineered safety features at least annually and as they become available in the market (e.g. safer anesthetic syringes, blunt suture needle, retractable scalpel or needleless IV systems).
• Place used disposable syringes and needles, scalpel blades and other sharp items in appropriate puncture- resistant containers located as close as feasible to the area where the items will be used.
• Do not recap used needles by using both hands or any other technique that involves directing the point of a needle toward any part of the body. Do not bend, break or remove needles before disposal.
• Use either a one-handed scoop technique or a mechanical device designed for holding the needle cap when recapping needles (e.g. between multiple injections and before removing from a non- disposable aspirating syringe).

Post Exposure Management and Prophylaxis

• After an occupational blood exposure, first aid should be administered at the earliest.
• Puncture wounds and other injuries to the skin should be washed with soap and water; mucous membranes should be flushed with water.
• No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission; however, use of antiseptics is not contraindicated.
• The application of caustic agents (e.g. bleach) or the injection of antiseptics or disinfectants into the wound is not recommended.
• Dental practitioner should provide information about the date, time and all the details of the exposure including the source material, details of the procedure being performed at the time of exposure and severity and type of exposure.
• Dental practitioners who have contact with patients can also be exposed to persons with infectious TB and should have a baseline tuberculin skin test (TST), preferably by using a two-step test, at the beginning of employment . Thus, if an unprotected occupational exposure occurs, TST conversions can be distinguished from positive TST results caused by previous exposures. The facility's level of TB risk will determine the need for routine follow-up TST's.
• Each occupational exposure should be evaluated individually for its potential to transmit HBV, HCV and HIV.

Medical Conditions, Work-Related Illness and Work Restrictions

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.

Maintenance of Records, Data Management and Confidentiality

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.

• Primary PPE used in oral health-care settings includes gloves, surgical masks, protective eyewear, face shields and protective clothing (e.g. gowns and jackets).
• All PPE should be removed before dental professionals leave patient- care areas.
• Reusable PPE (e.g. clinician or patient protective eyewear and face shields) should be cleaned with soap and water when visibly soiled, disinfected between patients, according to the manufacturer's directions.
• Wearing PPE reduces the risk of exposures to blood-borne pathogens.

General work clothes (e.g. uniforms, scrubs, pants and shirts) are neither intended to protect against a hazard nor considered PPE).

Masks, Protective Eyewear and Face Shields

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.

When using a mask

• Adjust it so that it fits snugly against your face.
• Keep beard and moustache groomed so that mask fits well.
• Change between patients if the mask gets wet.
• Remove as soon as treatment is over.
• Do not leave it dangling around your neck.
• Do not leave it in the operatory.
• When removing a mask handle it only by the elastic or cloth tie string.
• Never touch the mask itself.

Protective Clothing

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.

• Gloves should be worn for all dental procedures and when handling items or surfaces contaminated with body fluids.
• Remember: If you leave the chairside, remove the gloves and dispose of them immediately in the contaminated waste bin. Do not re-use gloves. Don a fresh pair on return to the chairside. Always remove gloves when using the telephone, computer keyboard or mouse. Never handle charts when gloved.
• On no account should gloves or masks be worn outside the clinical area.
• Hands and lower arm/wrist area should be washed in liquid soap and fully dried before gloving and after gloves are removed. Disposable towels should be used for drying hands. It is important that hands are thoroughly dried before gloving.
• Heavy duty gloves should be worn by the dental nurse when handling contaminated instruments to reduce the risk of percutaneous injury.
• Ensure that appropriate gloves of the correct size are readily accessible.

Types of Gloves and Gloving

• Medical gloves for patient examination and surgeon's gloves, are manufactured as single-use disposable items that should be used for only one patient, then discarded.
• Gloves should be changed between patients and when torn or punctured.
• Gloves can have small, unapparent defects or can be torn during use and hands can become contaminated during glove removal.These circumstances increase the risk of operative wound contamination and exposure of the hands of the dental professionals to microorganisms from patients.
• The hands should be dried thoroughly before donning gloves and washed again immediately after the glove is removed because bacteria can multiply rapidly in the moist environments underneath gloves.

Glove Integrity

• If the integrity of a glove is compromised (e.g. punctured), it should be changed as soon as possible.
• Washing latex gloves with plain soap, chlorhexidine or alcohol can lead to the formation of glove micropunctures and subsequent hand contamination, hence washing gloves in not recommended.
• The hands should be thoroughly dried after rubbing with alcohol before gloving, because hands still wet can increase the risk of glove perforation.

Sterile Surgeon's Gloves and Double-Gloving During Oral Surgical Procedures

• Wearing sterile surgeon's gloves during surgical procedures minimize transmission of microorganisms from the hands of surgeon to patients and prevent contamination of the hands of surgeon with the patient's blood and body fluids.
• Double gloving lowers the frequency of inner glove perforation and visible blood on the surgeon's hands.

Contact Dermatitis and Latex Hypersensitivity

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:

• Dental professionals allergic to latex should be provided with reduced protein, powder-free, non latex gloves. (e.g. nitrile or vinyl) powder- free and low-protein gloves are also available.
• Dental practices should be appropriately equipped to deal with potentially life- threatening anaphylactic reactions to latex. Procedures must be in place to respond to such emergencies in case they occur.
• Dental professionals and dental patients with allergy should not have direct contact with latex-containing materials and should be in a latex-safe environment with all latex-containing products removed from their vicinity.
• Dental patients with histories of latex allergy can be at risk from dental products (e.g. prophylaxis cups, rubber dams, orthodontic elastics and medication vials).
• Any latex-containing devices that cannot be removed from the treatment environment should be adequately covered or isolated.
• Persons might also be allergic to chemicals used in the manufacture of natural rubber latex and synthetic rubber gloves as well as metals, plastics or other materials used in dental care.
• Taking thorough health histories for both patients and dental professionals, followed by avoidance of contact with potential allergens can minimize the possibility of adverse reactions.

The following precautions should be considered to ensure safe treatment for patients

• Be aware that latent allergens in the ambient air can cause respiratory or anaphylactic symptoms among persons with latex hypersensitivity. Patients with latex allergy can be scheduled for the first appointment of the day to minimize their inadvertent exposure to airborne latex particles.
• Communicate with other dental professionals regarding patients with latex allergy (e.g. by oral instructions, written protocols and posted signage) to prevent them from bringing latex-containing materials into the treatment area.
• Frequently clean all working areas contaminated with latex powder or dust.
• Have emergency treatment kits with latex-free products available at all times.
• If latex-related complications occur during or after a procedure, manage the reaction and seek emergency assistance. Follow current medical emergency response recommendations for management of anaphylaxis.

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 :

1. The type of procedure.
2. The degree of contamination.
3. The desired persistence of antimicrobial action on the skin.

• Hand washing should be done before and after every patient contact.
• Use either a plain or antimicrobial soap and water for handwashing and hand antisepsis before routine dental examinations and nonsurgical procedures.
• If the hands are not visibly soiled, an alcohol-based hand rub is adequate.
• Skin bacteria can rapidly multiply under surgical gloves if hands are washed with non-antimicrobial soap. Thus, an antimicrobial soap or alcohol hand rub is must before surgical procedures.

Indications for Hand Hygiene include:-

• When hands are visibly soiled.
• After barehanded touching of inanimate objects likely to be contaminated by blood, saliva or respiratory secretions.
• Before and after treating each patient.
• Before donning gloves.
• Immediately after removing gloves.
• For oral surgical procedures, perform surgical hand antisepsis before donning sterile surgeon's gloves. Use either an antimicrobial soap and water or soap and water followed by drying hands and application of an alcohol- based surgical hand scrub product.

Technique

• Use soap and water to scrub hands and forearms till the elbow.
• Wash the palms, the web between the fingers, the webs again with an altered grip, palms to knuckle of opposite hands, thumbs clasped in opposing palm, tips of fingers against palms of apposing hand.
• A 2min scrub between clinical sessions is acceptable.
• The fingers must be adequately cleaned.
• If a non-detergent soap is used for the scrub, a longer scrub is required and a post scrub rinse and with a low surface tension antiseptic such as alcohol is required.
• After the scrub the hands are dried with a sterile hand towel.

Special Considerations for Hand Hygiene and Glove Use

• Use hand lotions to prevent skin dryness associated with hand washing.
• Consider the compatibility of lotion and antiseptic products and the effect of petroleum or other oil emollients on the integrity of gloves during product selection and glove use.
• Keep fingernails short with smooth, filed edges to allow thorough cleaning and prevent glove tears.
• Do not wear hand or nail jewelry if it makes donning gloves more difficult or compromises the fit and integrity of the glove.

Storage and Dispensing of Hand Care Products

• Liquid products should be stored in closed containers and dispensed from either disposable containers or containers that are washed and dried thoroughly before refilling.
• Soap should not be added to a partially empty dispenser, because this practice of topping off might lead to bacterial contamination.

1. Wash hands before and after wearing gloves.
2. Wash hands at other appropriate times.
3. Wear a new pair of gloves with each patient.
4. Wear protective eyewear and mask when procedure involves spatter or splashing .
5. Change the mask if wet.
6. Wear protective gowns when treating patients.
7. Infection control should be practiced as a team effort amongst all the dental staff members.
8. Staff should be immunized against infectious diseases.
9. Dental staff in contact with the patients should have received the Hepatitis B vaccine.
10. Use sterile solutions and sterile surgical gloves for surgical procedures.
11. Remove all personal protective equipments before leaving the patient care area.