Why do we need infection

control
protocols

Living on the edge

Contact with blood, oral and respiratory

secretions, and contaminated equipment
occurs

Proper procedures can prevent transmission

of infections.

IF SALIVA WERE RED

A novel demonstration first was given by James
Crawford in the 1970s using the wordings as, if
saliva were red.
Which demonstrated the cross contamination that
occurred from practitioners saliva covered fingers.
A red dye was added to the patients saliva so that
the dentist/assistant could visualize salivary
contamination.

A
few
Definitions
Sterilization:
A Process by which all microbial forms are
destroyed (Patterson 1932)
The process by which an article,
surface or medium is freed of all living
microorganisms either in the vegetative or
spore state

Disinfection:

The destruction or removal of all

pathogenic organisms, or organisms capable of
giving rise to infection.

 Sanitization:

The term is sometimes used as a

synonym for disinfection, particularly with
reference to food processing and catering.`

Antisepsis: Seps ( Greek word ) putrid

Used to indicate the prevention of

infection, usually by inhibiting the growth of
bacteria in wounds or tissues. Chemical
disinfectants, which can be safely applied to skin
or mucous membrane and are used to prevent
infection by inhibiting the growth of the bacteria
are called antiseptics.

 Bactericidal agents:

Agents, which are able to kill the

bacteria

Bacteriostatic agents:

Agents, which are used only to

prevent the multiplication of bacteria
which may however remain alive.

Antiseptic : A chemical that is applied to living

tissue such as skin and mucous membrane to

reduce the number of microorganisms present
through inhibition of their activity or
destruction

Disinfectant : A chemical used on non vital

objects to kill surface vegetative pathogenic

organisms, but not necessarily spore forms or
viruses
Definition according to Patterson 1932

History of Sterilization and

Chlorine water :LeFerne in 1843
Asepsis
Ignaz Semmelweis, in 1847 began using

chlorinated lime
Surgical cleanliness : Joseph Lister in 1867

Iodine as a wound dressing by Davies in 1893

Ignaz Semmelweis :
Father
of Infection
Father of Infection
Control
Discovered that the incidence of puerperal
Control
fever could be drastically reduced if the
physician washes his hands.
His concept was not accepted by the
medical and surgical community at the
time
Only after Pasteur, Koch, and Lister had
produced more evidence of the germ
theory and antiseptic techniques was the
value of hand washing appreciated.

Modes of Transmission
In the dental setting, possible modes of

transmission include:
direct contact with blood, oral fluids, or other

patient materials;
indirect contact with contaminated objects
droplet contact, (spray or spatter containing
microorganisms)
inhalation of evaporated microorganisms
("droplet nuclei)

Chain of Infection
Pathogen
Source

Susceptible Host

Entry

Mode

Chain of Infection
Susceptible host

Reservoir

Port of Entry

Port of Exit

Transmission

The chain of infection

example
Infectious agent
Hepatitis B

Susceptible host
Unvaccinated
Dental worker

Reservoir
The bloodstream

Port of Entry

Port of Exit

Puncture wound

Bleeding wound

Transmission
Direct via needle stick

Potential Routes of
Transmission of Bloodborne
Pathogens
Patient
Dentist/Assistant
Dentist/Assistant

Patient

Patient

Patient

Standard Precautions
Apply to all patients
Integrate and expand Universal Precautions
For diseases that are transmitted through airborne,

droplet, or contact transmission, standard

precautions should be coupled with expanded or
transmission-based precautions.

(isolation), adequate room ventilation, enhanced

respiratory protection for team members, or

postponement of non-emergency dental procedures.

Elements of Standard
Precautions

Handwashing

Use of gloves, masks, eye protection, and

gowns

Patient care equipment

Environmental surfaces

Injury prevention :

Handwashing
Hand washing is the cornerstone of the

infection control
First proposed by Ignaz Semmelweis in 1847

(Father of Infection control)

 Hand washing must be performed

meticulously so that every hand surface is

adequately cleaned. Special attention must be
paid to hand surfaces usually neglected when
washed.

After removing the gloves, hands must be

carefully washed as very often there are pores

in latex allowing the penetration of
contaminating matter.

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

Principles of Hand
Washing
Rubbing.

Lathering

Rinsing

Hand washing before gloving

Hand washing after glove removal

In oral surgical procedures, tearing of gloves

often occurs, causing an outpouring of

bacteria from the surgeons hands
Handwashing limits this bacterial

contamination and reduces epithelial debris

Types of Hand Washing

Handwashing

Washing hands with plain soap and water

Antiseptic handwash
Washing hands with water and soap or other
detergents containing an antiseptic agent

Alcohol-based

handrub

Rubbing hands with an alcohol-containing preparation

Surgical antisepsis
Handwashing with an antiseptic soap or an alcoholbased handrub before operations by surgical
personnel

Antiseptics used in hand washing

Chlorhexidine :This is 2-4% Chlorhexidine gluconate
with 4% isopropyl alcohol in a detergent solution
with a pH of 5-6.5.

Povidone iodine :It contains 7.5%-10% Povidone

iodine, with 0.75%-1% available iodine..
Parachlorometexylenol :It is bactericidal
fungicidal at 2% concentration.
Alcohol :Ethyl alcohol and isopropyl
Bactericidal at 70% concentration.

and

alcohol.

Technique for Hand Washing for minor

procedures
Wet your hands
Rub your hands together
Continue rubbing your hands for at least 20 seconds.
Rinse your hands well under running water.
Dry hands using a clean towel or allow them to air

dry.

Other recommendations for

Keep fingernails
short with smooth, filed edges
hand
hygiene
to allow thorough cleaning and prevent glove
tears .
Do not wear artificial fingernails or extenders

when having direct contact with patients at high

risk
Avoid wearing hand or nail jewelry if it makes

donning gloves more difficult or if it

compromises the fit and integrity of the glove.

THEATRE
ETTIQUETTE

SCRUBS AND SHOES

Scrubs comprise of pants/skirt and

shirt/blouse
Arms should end 4 inches above elbows
Legs should not drag on the floor

Shoes should be conducting.

Surgical hand scrubbing

All subnail contaminants should be removed with

a nail brush
Hands are held upright
Wet hands and arms till few inches above elbows
Scrubbing begins from the tip of one finger
Each finger is divided into 4 surfaces and each

surface receives 30 strokes

Ventral, dorsal and lateral surfaces of the hand

are washed
Arm is divided into thirds and each surface is

scrubbed again
Scrubbing procedes from fingers to elbows
Time 10 min for 1st scrub, with 5 min between

uncontaminated proccedures
Rinse excess soap but do not scrub
Dry with hand towel proceeding from fingers to

elbows

Gowning
Done after Scrubbing

in and before gloving

up
Gown is folded with

the inside surface

outside
Only the inside

surface is contacted
while gowning

Gowning with the help of the circulating nurse :

Pick up the sterile

gown after drying

scrubbed hands
Step away from the

area
The gown is held at

the neck taking care

that only the inside
surface is touched

Let the gown unfold completely

Locate the arm holes and push hands through

the holes making sure that the outside surface

is not contacted
The circulating nurse adjusts the gown from

the back and pulls it over the shoulders and

arms by holding the inside surface
The circulating nurse secures the gown at the

neck and waist level.

The final step is turning. Hand the card attached to

the tie to the circulator. Turn completely holding one

tie and take the opposite tie by pulling it from the
card without touching the card. Secure both ties
together
Gowning with the help of Scrub nurse :
After the surgeon dries his hands, the scrubbed and

gowned nurse takes the gown and lets it open,

touching only the outer surface.
The scrub nurse presents the gown to the surgeon,

and the surgeon pushes his hands into the arms

without touching the outside surface

The circulating nurse adjusts the gown from

the back and pulls it over the shoulders and

arms by holding the inside surface
The circulating nurse secures the gown at the

neck and waist level.

The scrub nurse then secures the ties at the

sides.

Gloves
Always were latex (or vinyl) gloves
Handwashing prior to gloving up
Single Use
For patients with confirmed HIV, HCV,HBV,

double gloves should be used

Preparation of Surgical
Important to reduce contamination by
Site
patients own normal flora as well as resistant
hospital acquired bacteria
Hair/shaving should ideally be done just prior

to surgical preparation

Circumoral preparation should precede intra

oral preparation

Iodophore compounds are the most effective

for skin preparation

Before preparation, lubricating ointment

should be applied to the eye, and the eye

should be taped shut

There are various techniques of painting of

the surgical site

It can be square painting, side to side painting

or circular painting
The most common is Circular painting, where

painting is done in concentric circles from

inside to outside
This prevents contamination of already

painted inside zone.

Operating Room
The operating room is just a clean room to do
Procedure
surgery. It is not a sterile room.
The operating theatre is cleaned after every

case, and fumigated using chemicals like

formaldehyde frequently, especially after a
contaminated surgery
All OT personnel are expected to wear clean

scrubs, masks, head covers, and shoes/shoe

covers before entering.

Once hand scrubbing has been performed the

operating surgeon and assistants have to wear

sterile surgical gowns before wearing sterile
gloves
Once scrubbed and gowned, the back and below

waist area is considered unsterile, so care must

be taken to keep the arms above waist level, and
not to back into any sterile equipment.
Also, instruments should not be passed from

behind the surgeons back.

Coughing and sneezing not allowed.

Draping
Covering a patient and surrounding areas with

a sterile barrier to create and maintain a

sterile field during a surgical procedure
Purpose : isolates the surgical area from parts

that have not been prepared & creates an

area of asepsis called a sterile field
Exposes only the surgical site and covers the

unprepared areas

Initial Drape : single thickness draw sheet 115

x 180 cms
Front Sheet : 2nd drape 115 x 175 cms.
Head draped with double sheet : Drape as

lower sheet, Hand towel as upper sheet.

Handle the drapes as little as possible.

Never reach across the operating table to drape the

opposite side
Hold the drapes high enough to avoid touching

nonsterile area
Hold the drape high until it is directly over the proper

area, then drop it down where it is to remain. NEVER

ADJUST ANY DRAPE.

Do not let the gloved hand touch the skin of the

patient
If a drape becomes contaminated, discard it

immediately.
If the end of a drape falls below waist level, do not

handle it further. Drop it and use another drape.

If in doubt about sterility, discard the drape.
If a hole is found in a drape after it is laid down,

cover the hole with another drape or discard the

entire drape.

Surgical Site Scrubbed and

Draped

Operation Rooms
Traditionally called Theatres because the

earlier operation rooms were designed like

theatres for teaching/viewing
Design Concepts have now changed to

include sterilization protocols and air flow

dynamics.

Zones in the OT
Protective zone
Clean Zone
Aseptic Zone
Disposal Zone
Reference : Indian Journal of Anesthesiology 2007 : Designing an ideal
Operating Room
Complex (S S Harsoor1, S Bala Bhaskar)

Basic Design
Big enough for free circulation
Two openings :
one towards scrub area
one towards sterile area.
Swing Doors.
Floor should be Marble or polished stone and

walls should be Glaze tiled.

No false ceiling

Ventilation
in
the
OT
Ventilation in the OT can be of 2 types :
Re-circulating
Non-recirculating

Directional Flow :
Negative Pressure : From outside to inside. Used for

highly infective rooms

Positive Pressure : From Inside to outside. Used for OTs

OR air changes are 25 changes per hour , positive pressure

compared with corridors temperature between 18 & 24 C

and humidity of 50 to 55%
Reference : ASA Guidelines : 2012 Operating Room Design Manual

Air Flow Dynamics in OT

It can be
Conventional : Turbulent
Airflow dynamics

Laminar : Further 2 types

Horizontal
Vertical

Reference : ASA Guidelines : 2012 Operating

Room
Design Manual

Cleaning and Sterilization of OT

Cleaning :
Complex
Disinfection :
Sterilization :

Formaldehyde
It is a commonly used compound for OT
Fumigation
Fumigation.

Recommended concentration is 500 ml of 40

% formaldehyde in 1 litre of water.

Procedure : Performed in closed and sealed

OT. Theatre needs to be shut for 12-14 hours

Newer Techniques
Bacillocid : Has a very good cleansing property along
with bactericidal, virucidal , sporicidal and fungicidal
activity.
1.6 Dihydroxy 11.2G ( Chemically bound formaldehyde)
Glutaraldehyde 5.0g
Benzalkonium chloride 5.0g
Alkyl urea derivatieves 3.0g
Sprayed or mopped liberally allowing 30 min contact time

Ultraviolet Radiation :
UV radiation to be done for 12-16 hours. And the switched off 2-

3 hours prior to any surgery.

Microbiological
Swabbing and culture
Monitoring
of OTs
for bacteria in OR
Quality of air in OR
Settle plate method.
1 plate of blood agar and 1 plate of SDA
Blood agar incubated at 37 C for 48 hrs & SDA
incubated at 27 C for 7 days.
Unacceptable : Bacterial colony count > 10 per plate
Fungal colony > one per plate

Masks
Masks : should withhold at least 95% of the

microorganisms.
Airborn diseases : fully adaptable to face, it

must be able to withhold particles and

microorganisms with a diameter up to 1m, at
a percentage of 95%
If the mask gets wet it must be immediately

discarded and replaced.

1)outer facing
media
3) breathable film
facing

2)filter
4)inner

Eye Protection
Required to protect the eyes from blood and

salivary spatter
Various types of glasses or plastic masks or

shields made of transparent materials.

Must be rinsed with abundant water and get

disinfected

Dental Clothing
Overalls/Scrubs should cover a big part of the

dentists body and hands.

They must be changed on a daily basis and

definitely as soon as they get stained.

If the operation is expected to involve a large

amount of bleeding or the patient is likely to

be seropositive, it is highly recommended that
specially designed single-use clothing be
used.

Surface Covering
Any surfaces/object not able to be sterilised or

disinfected, should be covered with appropriate

materials:
special rollers and plasticized paper sheets,
cellulose film,
aluminium foil,
self-adhesive films,
nylon cases,
latex and vinyl cases.

These protective coverings should be replaced after

every contact and every patient

Environmental Surfaces

May become contaminated

Not directly involved in infectious disease transmission
Do not require as stringent decontamination procedures

Categories of Environmental
Surfaces
Clinical contact surfaces

High potential for direct contamination from spray or spatter

or by contact with gloved hand

Housekeeping surfaces

Do not come into contact with patients or devices

Limited risk of disease transmission

Clinical Contact
Surfaces

Housekeeping Surfaces

General Cleaning Recommendations

Use barrier precautions

Physical removal of microorganisms by cleaning

Proper use of hospital disinfectants (Ex. SavlonChlorhexidine & Cetrimide)

Do not use sterilant/high-level disinfectants on

environmental surfaces

Cleaning Clinical Contact Surfaces

Risk of transmitting infections > housekeeping

surfaces

Surface barriers can be used and changed

between patients

or clean then disinfect using low- to

intermediate-level hospital disinfectant

eaning Housekeeping Surfaces

Routinely clean
Clean mops and cloths and allow to dry.

Use and Care of Sharp instruments

and Needles
should be used with special care so that

injuries are prevented.

Place within a solid, hard plastic container

Do not cap, bend or destroy the needles.

Do not overfill the plastic container, close

tightly and, finally, discard.

Used needles must not be recapped with both

hands
Needle should never point towards the body.

The 'one hand' technique to recap the needle

or a mechanical means designed to hold the

cap should always be used.

Scoop method of recapping

needles

Sterilization and Disinfection of

Instruments
Spaulding system (1972)

Sterilization of instruments
Stages of sterilizations
Pre cleaning disinfection(holding soln.):
Pre sterilization cleaning :
Sterilization
Aseptic storage

STERILIZATION
PHYSICAL AGENTS

HEAT-MOIST, DRY
IONIZING RADIATIONS
XRAYS, GAMMA RAYS

ULTRAVIOLET RAYS

FILTRATION

82

CHEMICAL AGENTS

S
T
E
R
I
L
I
Z
A
T
I
O
N

AGENTS ACTING ON CELL

MEMBRANE- SURFACE ACTIVE
AGENTS, PHENOLS, ORGANIC
SOLVENTS
AGENTS THAT ACTS ON FUNCTIONAL
GROUP OF PROTEINS
AGENTS THAT DENATURES PROTEINS
ACIDS, ALKALIES

HEAVY METALS
OXIDIZING AGENTS
DYES, ALKYLATING AGENTS

METHODS OF STERLIZATION IN OUR

INTREST AS CLINICIANS
Moist heat (autoclaving)

Dry heat (Hot air oven)

Chemicals (chemiclaving)

DO NOT DISINFECT WHEN YOU CAN STERILIZE

83

Manual Cleaning
Soak

until ready to

clean
Wear

heavy-duty utility
gloves, mask, eyewear,
and protective clothing

Automated Cleaning
Ultrasonic

cleaner

Instrument

washer

Washer-disinfector

Preparation and
Packaging
Critical

and semi-critical items that will be

stored should be wrapped or placed in
containers before heat sterilization

Hinged
Place
Wear

instruments opened and unlocked

a chemical indicator inside the pack

heavy-duty, puncture-resistant utility

gloves

Heat-Based Sterilization
Steam

under pressure (autoclaving):

Moist Heat
Gravity displacement
Pre-vacuum
Dry heat
Unsaturated chemical vapor

Steam Under Pressure :

Autoclave
Sterilization with STEAM UNDER PRESSURE
Time required at 121 deg C is 15 mins at 15 lbs of

pressure.

Advantages
Rapid and effective
Effective for sterilizing cloth surgical packs
and towel packs
Disadvantages
Items sensitive to heat cannot be sterilized
It tends to corrode carbon steel burs
and instruments

Denatures and coagulates the protein

higher efficiency
Unwrapped items
Lightly wrapped
Heavily wrapped

132*C
30lb/in2
121*C
15lb/in2
132*C
30lb/in2
121*C
15lb/in2
132*C
30lb/in2
121*C
15lb/in2

3 min
15 min
8 min
20 min
10 min
20 min

REQUIREMENTS:
Reach & maintain holding time and temperature
Have means to remove air, check efficiency
Ability to destroy spores
Large chamber size
Preferably with a drying cycle
89

Types of Autoclave
Downward Displacement:
Positive Pressure Displacement :
Negative Pressure Displacement :
Triple Vacuum Autoclave :

 Type "N" vs. Type "B : Each autoclave can be

classified as a type "N" unit or a type "B" unit. Type

"N" units do not use a vacuum to remove air from
the sterilization chamber, whereas type "B" units
do use a vacuum pump. The difference in operation
means type "N" autoclaves are suitable for a
specific type of load--for solid, unwrapped
instruments. Type "B" autoclaves can be used on
wrapped and hollow instruments, which means a
piece of equipment can be sterilized now for use
later.

CHEMICAL VAPOUR STERILIZERS

Operate by heating a deodorized alcohol, formaldehyde, and ethyl
methyl ketone solution, to 132oc at 20-40 lb/in2 for 20 minutes.

Advantages
o30 min cycle
Short flash cycles of 7 minutes
o Dullness, rust not present
o Instruments are dry at the end of the cycle.

Disadvantages
o good ventilation is essential
o extra cost

92

ETHYLENE OXIDE GAS

STERILIZATION

o A flammable, explosive and toxic gas

o MOA : Alkylation, denaturation of protein
o More potent in humid atmosphere
Advantage:
Can be used for any material

Disadvantage:
Time

Cost
Toxicity

93

DRY HEAT STERILISATION

Unwrapped loads 160*-170* for 1 hr

Wrapped > 1hr, upto 2 hrs
Proteins dehydrate & dry, resistance to denaturation increases
Acceptable items paper bags, Al foil, polyfilm plastic tubing

Advantages

Inexpensive
Greater capacity
Instruments dry at end of cycle
Doesnt corrode / rust, dull

Forced air convection units / rapid heat transfer

sterilisers:
Higher temp (190*C)
Controlled internal air flow- fan
6 min for unwrapped & 12 min for wrapped instruments
94

Disadvantages
Low-temp air pockets prevent

even distribution of heat

Long time cycle
Damage to handpieces
Less effective on wrapped
items

95

HOT BEAD / SALT STERILIZERS

For endo files & rotary instruments

Consists of a metal cup ( crucible )

in which glass beads or salt is
maintained

Beads can block root canal

Temp of 218-246*C

15 sec immersion required

96

MONITORING OF STERILIZATION

Physical
Chemical
Biological

Physical: Periodical observations of display or gauges

Chemical:
Heat sensitive chemical indicators

Process indicators:
Consists of a colour material either
liquid/paper that changes colour upon exposure to
appropriate sterilization cycle, implying that the load has
been processed.

 TST strips:

1. More recent and more advanced

2. Time-steam-temperature strips change colour when all
parameters have been adequately achieved in the
sterilization cycle.

98

BROWNE TUBES
glass tubes filled with fluid

Color change from red to

amber to green

Primarily used in hot air

ovens

2 typesChanges color after 1 hr at

150*C
Changes color after 12 min at
BOWIE
180*CDICK TAPE

Applied to articles
Brown stripes appear on tape.

99

BIOLOGICAL

Heat resistant Bacterial spores of the genus Bacillus.

If the spores are killed than the less resistant microbes are
killed.

Bacillus stearothemophillus : moist heat

Bacilus Subtilis : dry heat sterilizers., ETO units

Following each cycle the indicator strip should be sent for

culture.

100

101

RECENT ADVANCES
GAMMA RADIATION CHAMBERS
Used in many single-use medical supplies such as syringes,
catheters, IV sets, gloves, and face masks
Does not require a quarantine or post-sterilization treatment
Is easily validated
Penetrates every crevice of instruments

E- BEAM RADIATION
syringes & cardiothoracic devices
Shorter exposure time
Dosimetric release lets some products forgo sterility testing
Density of material limiting factor

102

UV light cabinets

Emission at 253.7nm (short wave ultraviolet)

Used because of their abiotic effect and ability to

produce photochemical changes in organic and
inorganic substances.

Potential to cause skin & eye burns

103

DISINFECTION AND DISINFECTANTS

1.DISINFECTANTS/STERILANTS2.HOSPITAL DISINFECTANTS WITH TUBERCULOCIDAL
ACTIVITY
3.NON TB CIDAL HOSPITAL DISINFECTANTS
4.SANITIZERS

104

IDEAL PROPERTIES OF DISINFECTANTS

Rapid disinfection
Broad spectrum biocidal action
Substantivity
Non-irritant
Economical
Reuse life of atleast 21 days when diluted
Change colour
Contain detergent
Anticorrosive
Have EPA approval

105

GLUTARALDEHYDE

High level immersion disinfectant

Acidic (pH 4 to 6.5), neutral (pH 7 to 7.5) and alkaline

(pH 7.5 to 8.5)

Effectiveness increases as pH increases greatest in

alkaline

Alkaline forms polymers which are not biocidal

prevented by stabilisers (phenolic buffer)

2%w/v solution

106
14

to 30 days

Advantages
Wide spectrum
Sporicidal
Active in presence of organic matter
Prolonged activated life
Sterilising heat labile materials (plastic, rubber)

Disadvantages
Longer immersion time
Irritant.
Corrosive, Toxic fumes
Carcinogenic in animals

107

PHENOLS

Lister in 1867 cytoplasmic poisons

1:32 dilution effective for 60 days if unused
Wide spectrum
Disinfectant in 10 minutes contact
Combined with 70% alcohol hard surface disinf

Chlorhexidine - biphenol - subcidal concentrations

diminishes pathogenicity of bacteria (Holloway, Bucknell
and Denton, 1986)

Hexachlorophene diphenyl alkane highly bactericidal

2 to 3% excellent skin disinfectant

108

ALCOHOL

Synergistic with low conc phenols

70% isopropyl alcohol, ethyl alcohol skin antiseptic
Advantages
Rapid bactericidal, tuberculocidal, viricidal
Economical
Only slightly irritating
Disadvantages
Not sporicidal
Diminished activity with bioburden
Damages rubber and plastic
Rapid evaporation rate
Conc > 70% : Dehydrates protein : insoluble film

109

CHLORINE PREPARATIONS

Chlorine plus Water oxidation into hypochlorous acid

Sodium Hypochlorite

One part of 5% NaOCl + 9 parts of water (1:10 dilution 5000 ppm of

sodium hypochlorite)

Advantages
Rapid action
Broad spectrum
Effective in diluted solution
Economical

Disadvantages
Chemically unstable
Diminished activity with organic matter
Irritate skin, eyes, mucous membrane
Corrosive
Discolouration
Unpleasant persistent odour
Degrades plastic and rubber
110

Chlorine dioxide

Sodium chlorite and organic acid

High level disinfectant
Sprayed or wiped
Advantages:
Instrumental or environmental surface germicidal
Disadvantages :
Discarded daily
Failure to readily penetrate organic debris
Protective eyewear, gloves required
Corrosive
Requires adequate ventilation

111

Iodophores

Complex of iodine and other organic compounds

(solubilizing agents or carrier polyvinyl pyrrrolidine
and ethoxylated non ionic detergents)
Release iodine in small increments
Slow release provide continuous action
Advantages
Broad antibacterial action
Leaves a residual action
Non-irritant
Economical

Disadvantages
Discolours some surfaces when applied continuously
112

DETERGENTS (SURFACE ACTIVE SUBSTANSES)

Lower surface tension efficient cleaning
Alter the osmotic barrier of cell membrane increase cell permeability
Three types
1.Non-ionic No antimicrobial activitity
2.Anionic Eg. Synthetic anionic detergents and soaps
3.Cationic Quaternary ammonium compounds (QUATs)

113

Sterilization of Handpiece
Step 1. Run, Wash, Dry
Step 2. Reconnect, Run, Disconnect
Step 3. Lubricate, Reconnect, Run
Step 4. Disconnect, Pack and seal, Autoclave

Sterilization of Burrs
Clean and Wash, Then Sterilize :
1) Carbon Steel burrs : Chemiclave/Ethelyne

oxide/Chemical Solutions
2) Stainless Steel/Tungsten Carbide : Autoclave
3) Dry heat : All burrs.
4) Immersion Disinfection

Sterile Irrigating
Solutions
Sterile
Use

Saline or Sterile Water

devices designed for the

delivery of sterile irrigating fluids

Saliva Ejectors
Previously

suctioned fluids might be retracted

into the patients mouth when a seal is
created

Do

not advise patients to close their lips

tightly around the tip of the saliva ejector

Suction Machines and

Suction Machine tubing and bottles harbour
Bottles
biofilms
Washed and flushed with disinfectant
Never be emptied into sinks or open drains

Dental Unit Waterlines and Biofilm

Microbial biofilms form in small bore tubing.

Associated with higher baseline levels of

Pseudomonas aeruginosa,Legionella
pneumophila, nontuberculous mycobacteria
andAcanthamoebaspp.
Biofilms can be controlled by :
Filters:
Autoclavable systems
Chemical products (disinfectants0

Occupational Infections in
Dentistry
Identified risk of occupational exposure to

blood-borne pathogens : (HIV) (HBV) (HCV).

Sharp injuries occur because of a small

operating field, frequent patient movement,

and the variety of sharp instruments used.

Bacteria that May Be

Transmitted
Tuberculosis :Mycobacterium tuberculosis,
Aerosolized bacteria.
Proper masks are not used
Suspected TB patients should be diagnosed and

treated.
Emergency dental treatment should be done

using proper precautions.

Staphylococcus aureus
S. aureus and MRSA: Common cause of
nosocomial infections.
Oral, nasal passages : Natural habitat
Can be transmitted to patient

Other Bacteria
Beta helolytic streptococci, Streptococcus
pneumoniae, Haemophilus influenzae,
Neisseria meningitidis, Corynebacterium
diphtheriae and Bordetella pertusis.

Viral Infections
HIV, HBV, HCV
Are
Can
Are

transmissible in health care settings

produce chronic infection

often carried by persons unaware of their

infection

Factors Influencing
Occupational Risk of
Bloodborne
Virus
Infection
Frequency of infection among patients
Risk

of transmission after a blood

exposure (i.e., type of virus)

Type

and frequency of blood contact

Infection of concern in
Dentistry
Infectious
Habitat
TransPotential
Organism

mission

Pathology

Vaccine

Hepatitis B Virus

Liver

B, S, T, Sw.

Hepatocellular
carcinoma

Hepatitis C virus

Liver

Hepatocellular
carcinoma

Hepatitis D virus

Liver

Hepatocellular
carcinoma

HSV I & II

NP

NPS, B, S,

Oral, eye, finger

lesions

HIV

T-4 Cell

AIDS

Measles(Rubeola)

NP

NPS, B, S,

Generalized vesicular Y
rash

Measles(Rubella)

NP

NPS, B, S,

Generalized vesicular Y
rash

Infectious
Organism

Habitat

Transmission

Potential
Pathology

Neisseria
Gonorrhoeae

Mouth,
NP

B, S, T, Sm.

Treponema
Palladium

Blood
Mouth

Syphilis

Micobacterium
tuberculosis

Pharynx

NPS

Tuberculosis

Influenza virus

NP

NPS

Flu, Common cold N

Rhino virus

NP

NPS

Flu, Common cold N

Adeno virus

NP

NPS

Flu, Common cold Y

Gonorrhoeae

Vaccine
N

Average Risk of Bloodborne

Virus
Source
Risk
Transmission after Needlestick
HBV

HBsAg+ and HBeAg+

22.0%-31.0% clinical hepatitis; 37%62% serological evidence of HBV

infection

HBsAg+ and HBeAg-

1.0%-6.0% clinical hepatitis; 23%37% serological evidence of HBV

infection

HCV
HIV

1.8% (0%-7% range)

0.3% (0.2%-0.5% range)

Concentration of HBV in
Body Fluids
High
Detectable

Blood
Urine
Serum
Wound exudates
Sweat

Milk

Moderate

Low/Not

Semen
Vaginal Fluid
Saliva

Feces

Tears
Breast

Hepatitis B Vaccine

Vaccination should result in serocoversion

Monitor Titres
Vaccinate all at risk of exposure to blood
Provide access to qualified health care

professionals

Test for anti-HBs 1 to 2 months after 3rd

dose

 Seroconversion - Immune
No seroconversion :
Second 3 dose series
No seroconversion : Check carrier state.
Nonresponsive, non carriers to be advised

precautions

Hepatitis C
HCV transmission risk is 1.8% ,Chronicity in 85%

infected
Determine HHH status
LFTs and HCV RNA PCR testing four weeks after

exposure, antibody HCV testing at three and six

months post-exposure.
Baseline LFTs ,HCV antibody test on the day of the

exposure
Currently there is no PEP for Hepatitis C.

HIV/AIDS
Risk 0.2 to 0.3% for parenteral exposures and

0.1% or less for mucosal exposures.

HIV PEP : Combination of 2/3 drugs
PEP started within 1-2 hrs of exposure
Post-exposure prophylaxis for HIV is:

Recommended for significant percutaneous

exposure to blood or body substances involving

a high risk of HIV transmission
Offered (but not actively recommended) for
ocular mucous membrane or non-intact skin
exposure to blood or body substances
Not offered for exposure to any non-bloody
urine,saliva or faeces

For skin if broken :

Immediate washing
Do not scrub.
Do not use antiseptics or skin washes .

First aid in management of

exposure
After a splash of blood or body fluids on unbroken skin:
Wash
Do not use antiseptics
For the eye:
Irrigate
Leave contact lens in place for 1st rinse, then remove and rerinse
Do not use soap or disinfectant.

First
For mouth: aid in management of
Spit fluid out immediately
exposure
Rinse
Do not use soap or disinfectant

Dont
Do not
Do not
Do not
Do not

panic
suck
squeeze
use antiseptic

PEP for HIV

Management of exposure

Immediate decontamination

Initiation PEP

Baseline bloodtests

Source of exposure Voluntary testing for HHH

Exposed Individual :Testing for antibodies and titres

Categories of
Exposure
Mild Exposure

Mucous membrane/non-intact skin with small

volumes
a superficial wound (erosion of the epidermis) with
a plain or low calibre needle,
contact with the eyes or mucous membranes,
subcutaneous
injections
following
small-bore
needles.

Moderate
Exposure

Mucous membrane/non intact skin with large

volumes OR
percutaneous superficial exposure with solid needle
E.g. : a cut or needle stick injury penetrating gloves

Severe
Exposure

percutaneous with large volume

An accident with a high calibre needle (>18 G)
visibly contaminated with blood;
Deep wound (haemorrhagic wound and/or very
painful); transmission of a significant volume of
blood;
An accident with material that has previously been

Selection of PEP
depending upon
Severity of Exposure

Exposur
e

Status of source

HIV+ and
Asymptomatic

HIV+ and
Clinically
symptomatic

HIV status unknown

Consider 2drug PEP

Start 2-drug PEP

Consider 2-drug PEP

Moderate Start 2-drug

PEP

Start 3-drug PEP

Consider 2-drug PEP

Severe

Start 3-drug PEP

Consider 2-drug PEP

Mild

Start 3-drug
PEP

PEP Regimen for HIV

Medication
Zidovudine (AZT)

2-drugregimen
300 mg twice a
day
Stavudine (d4T)
30 mg twice a
day
Lamivudine (3TC) 150 mg twice a
day
ProteaseInhibitors

3-drugregimen
300 mg twice a day
30 mg twice a day
150 mg twice a day
1stchoice
Lopinavir/ritonavir (LPV/r)
400/100 mg twice a day or
800/200 mg once daily with meals
2nd choice
Nelfinavir (NLF)
1250 mg twice a day or
750 mg three times a day with empty
stomach
3rdchoice
Indinavir (IND)
800 mg every 8 hours and drink 810
glasses (1.5 litres) of water daily

PEP for Hepatitis

Hepatitis B
Vaccinnated : Booster.
If being vaccinated/non-responder : hepatitis B
immune globulin(HBIG) and the vaccine
(accelerated dose).
Known non-responders HBIG and the
vaccine(accelerated dose).
Hepatitis C
No PEP
Monthly HCV RNAPCR,
Seroconversion : interferon, with possibleribavirin.

Herpes Simplex
Vesicular fluid : the most infectious but viral

shedding continues from resolving (crusting)

herpetic lesions.
Gloves : Do not give adequate protection
Standard Precautions and Transmission-Based

Precautions should be followed.

Elective care should be deferred until all

lesions heal.

Varicella/Herpes Zoster
Serious consequences in pregnant women

and immunocompromised persons of all ages.

Airborne infection can occur
Standard Precautions and Transmission control

protocols must be followed

The patient should be treated in isolation

Post-Exposure Evaluation and

Follow-up
Employer must:
Document exposure and circumstances
Document source individual
Source individuals blood tested
If source is known to be infected, blood test is
not necessary.
Employees blood is tested.
If employee refuses HIV testing, then blood is
stored at least 90 days.
Confidential medical evaluation
When indicated use post-exposure prophylaxis
which will prevent HIV infection

Conclusion
Take action to stay healthy
Get vaccinated against hepatitis B and other
vaccine preventable diseases.
Report occupational injuries and exposures
immediately.
Follow the advice of the medical care provider
evaluating your occupational exposure.
Avoid contacting blood/body fluids
Always use standard precautions and treat
every patient as if infectious.
Wear gloves, protective clothing, and face and
eye protection and handle sharps with care.
Use mechanical devices to clean instruments
whenever possible.

 Limit the spread of contamination

Set up the operatory before beginning treatment.
Cover surfaces that will be contaminated
Minimize splashes and spatter.
Properly dispose of all waste.
Make objects safe for use
Know the different sterilization/decontamination

processes.
Be familiar with various chemical germicide
solutions.
Monitor processes to make sure they are working
as they should.

References
Oral and Maxillofacial Surgery Vol 1: Daniel M Laskin
Textbook of Oral & Maxillofacial Surgery : Gustav

Kruger
Centre for Disease Control and Prevention :
Guidelines for Infection Control 2003
Australian Dental Council : Guidelines for infection
control 2009
Indian Journal of Anesthesiology
Americal Society of Anesthesiology : 2012 operating
room design manual
Textbook of Microbiology : Ananthanarayan
NACO guidelines for control and Prevention of
HIV/AIDS