Guide Lines for Infection Control in Dental Clinic

1. 1 The way to infection control in dental clinics Introduction: The unique nature of dental procedures, instrumentation and patient care settings require specific strategies directed to the prevention of transmission of diseases among dental health care workers and their patients. Disease: impairment of normal functioning, manifested by signs and symptoms. Infection: state produced by an infected agent in or on a suitable host, host may be or may not have signs or symptoms. Carrier: individual harbors the agent but does not have symptoms (person can infect others). Factors that allow or aid infection: = The presence of pathogenic micro-organisms. = There must be a portal of entry via which the organisms invade and colonize the susceptible host. Medical history A thorough medical history should be taken and up-dated at subsequent examinations. Medical history screening is essential in alerting the clinician to medical problems that could, in conjunction with dental treatment, adversely affect the patient. Protective measures Protection can be achieved by a combination of immunization procedures, use of barrier techniques and strict adherence to routine infection control procedures. (a)Immunization: All dental health care workers are advised to be immunized against HBV unless immunity from natural infection or previous immunization had been documented (b) Protective coverings: =Uniforms: Uniforms should be changed regularly and whenever soiled. Gowns or aprons should be worn during procedures that are likely to cause spattering or splashing of blood. =Hand protection: Gloves must be worn for procedures involving contact with blood, saliva or mucous membrane. A new pair of gloves should be used for each patient. If a gloves damaged, it must be replaced immediately. Hands should be washed thoroughly with a proprietary disinfectant liquid soap prior to and immediately after the use of gloves. Disposable paper towels are recommended for drying of hands. Any cuts o abrasions on the hands or wrists should be covered with adhesive waterproof dressings at all times. =Protective glasses, masks or face shields Protective: Glasses, masks or face shields should be worn by operators and close-support dental surgery assistants to protect the eyes against the spatter and aerosols which may occur during cavity preparation, scaling and the cleaning of instruments. I Infection nfection Control in Dental Clin Control in Dental Clinic ic Dr. M Dr. Mohammed Alruby ohammed Alruby

2. 2 (c)Sharp instruments and needles: Sharp instruments and needle should be handled with great care to prevent unintentional injury. Needles should never be recapped by using both hands indirect contact or by any other technique that involves moving the point of a used needle towards any part of the body. The needle can be recapped by laying the cap on the tray, placing the cap in a re- sheathing device or holding the cap with forceps before guiding the needle into the cap. (d)First aid and inoculation injuries: In the event of a skin puncture by a contaminated instrument, the wound should be encouraged to bleed and washed thoroughly with running water All incidents should be reported to the clinic. Where there is reason to be concerned about the possible transmission of infection, advice on appropriate serologic testing, medical evaluation and follow-up could be sought from Accident and Emergency Department Successful infection prevention program A successful infection prevention program depends on: 1-Developing standard operating procedures. 2- Evaluating practices and providing feedback to dental health care personnel (DHCP). 3- Routinely documenting adverse outcomes (e.g., occupational exposures to blood) and work-related illnesses in DHCP. 4- Monitoring health care associated infections in patients. Standard Precautions Standard Precautions: are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These practices are designed to both protect DHCP and prevent DHCP from spreading infections among patients. Standard Precautions include: 1-Hand hygiene. 2-Use of personal protective equipment (e.g., gloves, masks, eyewear). 3-Respiratory hygiene / cough etiquette. 4-Sharps safety. 5-Safe injection practices (i.e., aseptic technique for parenteral medications). 6- Sterile instruments and devices. 7-Clean and disinfected environmental surfaces. Each element of Standard Precautions is described in the following sections. Education and training are critical elements of Standard Precautions, because they help DHCP make appropriate decisions and comply with recommended practices. 1-HAND HYGIENE: 1- Perform hand hygiene. a. When hands are visibly soiled. b. After bare hand touching of instruments, equipment, materials, and other objects likely to be contaminated by blood, saliva, or respiratory secretions. C. Before and after treating each patient. I Infection nfection Control in Dental Clin Control in Dental Clinic ic Dr. M Dr. Mohammed Alruby ohammed Alruby

3. 3 d. Before putting on gloves and again immediately after removing gloves. 2. Use soap and water when hands are visibly soiled (e.g., blood, body fluids); otherwise, an alcohol-based hand rub may be used. 2-PERSONAL PROTECTIVE EQUIPMENT (PPE): 1-Provide sufficient and appropriate PPE and ensure it is accessible to DHCP. 2-Educate all DHCP on proper selection and use of PPE. 3-Wear gloves whenever there is potential for contact with blood, body fluids, mucous membranes, non-intact skin or contaminated equipment. a- Do not wear the same pair of gloves for the care of more than one patient. b- Do not wash gloves. Gloves cannot be reused. c- Perform hand hygiene immediately after removing gloves. 4- Wear protective clothing that covers skin and personal clothing during procedures or activities where contact with blood, saliva, or OPIM (other potential infectious materials) is anticipated. 5- Wear mouth, nose, and eye protection during procedures that are likely to generate splashes or spattering of blood or other body fluids. 6- Remove PPE before leaving the work area. 3-RESPIRATORY HYGIENE / COUGH ETIQUETTE: 1- Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing throughout the visit. a. Post signs at entrances with instructions to patients with symptoms of respiratory infection to: I. Cover their mouths / noses when coughing or sneezing. ii. Use and dispose of tissues. iii. Perform hand hygiene after hands have been in contact with respiratory secretions. b. Provide tissues and no-touch receptacles for disposal of tissues. c. Provide resources for performing hand hygiene in or near waiting areas. d. Offer masks to coughing patients and other symptomatic persons when they enter the dental setting. e. Provide space and encourage persons with symptoms of respiratory infections to sit as far away from others as possible. If available, facilities may wish to place these patients in a separate area while waiting for care. 2- Educate DHCP on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of a respiratory infection. 4- SHARPS SAFETY: Consider sharp items (e.g., needles, scalars, 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. Do not recap used needles by using either hands or any other technique that involves directing the point of a needle toward any part of the body. Use either a one-handed scoop I Infection nfection Control in Dental Clin Control in Dental Clinic ic Dr. M Dr. Mohammed Alruby ohammed Alruby

4. 4 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). Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as possible to the area where the items are used. 5- SAFE INJECTION PRACTICES: 1-Prepare injections using aseptic technique in a clean area. 2- Disinfect the rubber septum on a medication vial with alcohol before piercing. 3-Do not use needles or syringes for more than one patient (this includes manufactured prefilled syringes and other devices such as insulin pens). 4-Medication containers (single and multi-dose vials, ampules, and bags) are entered with a new needle and new syringe, even when obtaining additional doses for the same patient. 5-Use single-dose vials for parenteral medications when possible. 6-Do not use single-dose (single-use) medication vials, ampules, and bags or bottles of intravenous solution for more than one patient. 7-Do not combine the leftover contents of single-use vials for later use. 8- The following apply if multi-dose vials are used: a. Dedicate multi-dose vials to a single patient whenever possible. b- If multi-dose vials will be used for more than one patient, they should be restricted to a centralized medication area and should not enter the immediate patient treatment area (e.g., dental operatory) to prevent inadvertent contamination. c. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated for single-patient use and discarded immediately after use. d. Date multi-dose vials when first opened and discard within 28 days, unless the manufacturer specifies a shorter or longer date for that opened vial. 9- Do not use fluid infusion or administration sets (e.g., IV bags, tubings, connection) for more than one patient. 6-STERILIZATION AND DISINFECTION: 1-Clean and reprocess (disinfect or sterilize) reusable dental equipment appropriately before use on another patient. 2- Clean and reprocess reusable dental equipment according to manufacturer instructions. If the manufacturer does not provide such instructions, the device may not be suitable for multi-patient use. a.Have manufacturer instructions for reprocessing reusable dental instruments / equipment readily available, ideally in or near the reprocessing area. 3- Assign responsibilities for reprocessing of dental equipment to DHCP with appropriate training. 4-Wear appropriate PPE when handling and reprocessing contaminated patient equipment. I Infection nfection Control in Dental Clin Control in Dental Clinic ic Dr. M Dr. Mohammed Alruby ohammed Alruby

5. 5 4-Use mechanical, chemical, and biological monitors according to manufacturer instructions to ensure the effectiveness of the sterilization process. Maintain sterilization records in accord 7-ENVIRONMENTAL INFECTION PREVENTION AND CONTROL: 1-Establish policies and procedures for routine cleaning and disinfection of environmental surfaces in dental health care settings. a- Use surface barriers to protect clinical contact surfaces, particularly those that are difficult to clean (e.g., switches on dental chairs, computer equipment) and change surface barriers between patients. b- Clean and disinfect clinical contact surfaces that are not barrier-protected after each patient. Instrument sterilization All instruments should be cleaned thoroughly before sterilization by rinsing and scrubbing with detergent and water. Splashing of water should be avoided. Heavy duty gloves and, where appropriate, face protection shield, should be worn. Items which will penetrate tissues must be sterilized in an autoclave or hot air sterilizer. Items which will touch mucous membrane but not penetrate tissues should similarly be sterilized by heat, or, if not possible, disinfected, e.g., by immersion in 2% glutaraldehyde solution in a closed container according to the manufacturer’s instructions. All chemical residues must then be removed by thorough rinsing before use or storage. Hand pieces, ultrasonic scalar inserts/tips and air-water syringe tips where detachable should be flushed for 30 seconds, dismantled, cleaned, oiled where required, and autoclaved between patients. Hand pieces which cannot be autoclaved are disinfected with an appropriate verucidal agent. Following sterilization, all instruments should be stored in clean containers to prevent recontamination. Surgical and endodontic instruments should be kept in closed containers. It may be necessary to re-sterilize them immediately before they are used and care should be taken to ensure the instruments are cool prior to use. 1.Surface disinfection: Surfaces that are likely to become contaminated may be de-contaminated after treatment or protected with disposable coverings before they become contaminated. Effective cross-infection control is aided by a strict system of zoning and the use of sterilizable trays. Procedures should be adopted which limit the areas touched and contaminated each time a patient is treated. Between clinical sessions, work surfaces should be thoroughly cleaned and decontaminated with ethyl alcohol (70%). If there is visible blood or pus, the surface should be cleaned and disinfected with sodium hypochlorite (0.5%), followed by water rinse. Protective gloves should be worn and care taken to minimize direct skin, mucosal or eye contact with these disinfectants. 2. Aspiration and ventilation: I Infection nfection Control in Dental Clin Control in Dental Clinic ic Dr. M Dr. Mohammed Alruby ohammed Alruby

6. 6 The use of high volume aspiration will reduce any risk of cross-infection from aerosols. The risk is further reduced by good ventilaton. The tubings of high volume aspirators and saliva ejectors should be changed between patients or using (sodium hypochlorite, 0.1%) regularly or according to the manufacturer’s instructions. 3. Disposal of waste: Sharp items including needles and scalpels should be placed into puncture proof containers which should be securely sealed. These, together with all medical waste must be disposed of in red bags, securely fastened. Red plastic bags are to be picked up by a special collection service for hospitals and clinics. Non infective waste should be disposed of in thick black plastic bags securely fastened. Liquid waste should be carefully poured into a drain and then flushed with water. Spatter and splash should be avoided. 4.Laboratory items: Impressions and appliances should be rinsed thoroughly to remove all visible blood and debris. Gloves should be worn when handling impressions and pouring models. Certain types of impression material (silicone, polysulphur) can be disinfected by total immersion in glutaraldehyde (2%) or sodium hypo chloride (0.1%). Other materials (alginate, polyether) may be disinfected by submerging for several seconds in sodium hypo chloride (0.1%), which should then be wrapped in a hypochloride saturated paper towel and kept in a closed container for the recommended disinfectant time. 5. Additional precautions to be taken when performing invasive procedures on HIV infected individuals: a-If possible, schedule the patient surgery at the end of the list. b. The team should be limited to essential members of staff and the procedures should be performed by experienced, fully trained staff. d. The operator should wear two pairs of gloves. Plastic gown, cap mask and protective eye wear should be worn. c. All procedures should be performed in a way which minimizes the formation of droplets, spatter and aerosols, utilizing high volume vacuum aspirators, rubber dams where appropriate and proper patient positioning. Ultrasonic scalars should be avoided. d. Avoid the use of instruments which cannot be easily decontaminated. Instruments and tools used should be handled and cleansed by experienced staff before autoclaving. e. After the operation, all surfaces inside the surgery and equipment should be cleaned and decontaminated with appropriate disinfectants. I Infection nfection Control in Dental Clin Control in Dental Clinic ic Dr. M Dr. Mohammed Alruby ohammed Alruby

7. 7 Recommended methods for dental items Item Amalgam/composite carrier articulators Attachment dental units Bracket table Recommended method Wipe with70% ethyl alcohol Wipe with70% ethyl alcohol Wipe 2% glutaraldehyde, rinse Wipe with 70% ethyl alcohol. But if there is invisible blood or pus, clean and disinfect with 0.2% of sodium hypochloride, rinse Clean with metallic brush and detergent, autoclave. Alternative method Wipe with 70% alcohol Burs-- diamond Burs: steel, tungsten, carbide. Clean with metallic brush and detergent, rinse, dry, and dry heat Clean brush and detergent, rinse, dry, immerse in 2% glutaraldehyde for 10 hours, rinse with metallic Dental chairs Clean with detergent and water, if there is visible blood or pus, clean and disinfect with 0.5% of sodium hypochloride or 2% glutaraldehyde, rinse Clean with detergent and water, autoclave, store in covered pack or container. Clean with detergent and water, if contaminated with blood immerse in 0.1% sodium hypochloride for 10 minutes, and rinse. Clean with detergent and water, autoclave, store in covered pack or container. Disposable Flush for 30 seconds, clean with detergent and water, oil, and autoclave. 0 Dental mirrors Denture Extraction forceps Gloves Hand pieces, air motor for low speed hand pieces Flush for 30 seconds, clean with detergent and water, surrounded the hand piece by a gauze pack soaked glutaraldehyde for 10 minutes, rinse water oil, in 2% with I Infection nfection Control in Dental Clin Control in Dental Clinic ic Dr. M Dr. Mohammed Alruby ohammed Alruby

8. 8 Item Alginate: with plastic trays Recommended method Rinse get a rid of excess water, spray with 0.1% sodium hypochloride, put in closed container minutes Rinse get a rid of excess water, spray glutaraldehyde, put in closed container for10 minutes Rinse, immerse glutaraldehyde minutes, rinse. disposable Alternative method for10 Alginate with metals trays with 2% Rubber base materials in 2% 10 for Injection needles for local anesthesia Instrument trays Clean with detergent and water, autoclave. Orthodontic bands and pliers Clean with detergent and water, autoclave. Clean with detergent and water, autoclave. disposable Wipe with 0.1% sodium hypochloride Clean with detergent and water Clean with detergent and water, autoclave. Clean and autoclave Polishing stone Cups and brushes Protective plastic glasses and shield Root canal instruments Rubber dam clamps Rubber dam forceps Clean, glutaraldehyde minutes, rinse immerse in 2% 10 for Rubber dam punches Clean with detergent and water disposable Clean with detergent and water, and autoclave Saliva ejectors Saliva ejectors metallic I Infection nfection Control in Dental Clin Control in Dental Clinic ic Dr. M Dr. Mohammed Alruby ohammed Alruby

9. 9 item Scalpel blades Recommended method Alternative method disposable Stainless steel instruments Clean with detergent and water, autoclave, stored in covered pack or container Dry heat Suction tips disposable Suction tube adaptor Wipe with 70% alcohol each use, autoclave weekly. Surgical instruments Clean with detergent and water, autoclave, stored in covered pack or container Dry heat Syringe, local anesthesia Clean with detergent and water, autoclave, stored in covered pack or container Dry heat Ultrasonic scalar tips and inserts Clean with detergent and water, autoclave, stored in covered pack or container Wax bit block, and wafer Rinse, immerse in 0.1% sodium hypochloride for 10 minutes, rinse. I Infection nfection Control in Dental Clin Control in Dental Clinic ic Dr. M Dr. Mohammed Alruby ohammed Alruby

10. 10 Notes: 1-Role of nurses to doctors: firstly, to protect patient, secondly, help doctors 2-All areas that surrounds doctor and may will be touch, must be covered 3-Do not touch desk, door, cabinet, telephone, dental chair, basin, your lab coat, and tap, while you wearing the infected or non-infected gloves. 4-If it urgently to touch anything should remove the gloves firstly or covering it firstly. 5-How many contra angle in each clinic? (How many patients come to each clinic per-day?) 6- Air tip should be disposable (preferable) and if it is metal must have a lot of number to accommodate all patients per-day 7-Suction tips must be disposable. 8-The drawer’s hands of cabinet must be covered between patients or only touch by cleaned glove. 9- During alginate mixing, take care about touching spatula or rubber bowel by infected glove. 10- For example, during composite restoration: composite syringe, itch and bond bottle should be touch by new gloves or nurse can help doctor for that. 11- Keep in your mind that the patient’s relatives observe everything in the clinic during any procedure. 12- Nurse and doctor should be mindful for everything doing to the patient. 13- Must be respect the patient’s privacy when present in the clinic so do not open the door more than one time under any situation. 14- Do not talking with the nurse about another patient’s behavior (respect privacy) 15- Take care for the following when the patients in your clinic: Cough, running nose, burping, hum, hiccough. Also the doctor and nurse must be: presentable, have good smell, have good manner, honest, faithful and reasonable all the times I Infection nfection Control in Dental Clin Control in Dental Clinic ic Dr. M Dr. Mohammed Alruby ohammed Alruby