infection control in orthodontics


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  • Plain soap is good for reducing bacterial counts, but antimicrobial soap is better and alcohol-based handrubs are the best, providing activity that prevents or inhibits survival of microorganisms after the product is applied.
  • This slide shows some examples of clinical contact surfaces, including a light handle, countertop, bracket tray, dental chair, and door handle (shown by arrows).
    Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
  • Because clinical contact surfaces come into direct contact with contaminated gloves, instruments, spray or spatter, their risk of transmitting infection is greater than for housekeeping surfaces. These surfaces can subsequently contaminate other instruments, devices, hands, or gloves.
    Surface barriers can be used to protect clinical contact surfaces and changed between patients. Surface barriers are particularly useful for surfaces that are hard to clean, such as switches on dental chairs. This practice will also reduce exposure to harmful chemical disinfectants.
    If surface barriers cannot be used, clean and then disinfect the surface with an EPA-registered hospital disinfectant effective against HIV and HBV (low-level disinfectant). If the surface is visibly contaminated with blood or other patient material, clean and then disinfect the surface with an EPA-registered hospital disinfectant with a tuberculocidal claim (intermediate-level disinfectant).
  • There are three categories of patient-care items depending on their intended use and the potential risk of disease transmission.
    Critical items penetrate soft tissue or contact bone, the bloodstream, or other normally sterile tissues of the mouth. They have the highest risk of transmitting infection and should be heat-sterilized between patient uses. Alternatively, use sterile, single-use disposable devices.
    Examples include surgical instruments, periodontal scalers, scalpel blades, and surgical dental burs.
  • Semi-critical items contact only mucous membranes and do not penetrate soft tissues. As such, they have a lower risk of transmission.
    Because most items in this category are heat-tolerant, they should be heat sterilized between patient uses. For heat-sensitive instruments, high-level disinfection is appropriate.
    Examples of semi-critical instruments include dental mouth mirrors, amalgam condensers, and impression trays. Dental handpieces are a special case. Even though they do not penetrate soft tissue, it is difficult for chemical germicides to reach the internal parts of handpieces. For this reason, they should be heat sterilized using a steam autoclave or chemical vapor sterilizer.
  • Noncritical instruments and devices only contact intact (unbroken) skin, which serves as an effective barrier to microorganisms.
    These items carry such a low risk of transmitting infections that they usually require only cleaning and low-level disinfection. If using a low-level disinfectant, according to OSHA, it must have a label claim for killing HIV and HBV. However, if an item is visibly bloody, it should be cleaned and disinfected using an intermediate-level disinfectant before use on another patient.
    Examples of instruments in this category include X-ray head/cones, facebows, pulse oximeter, and blood pressure cuff.
  • This is to prevent spray and splatter which is increased due to the small size of the sinks.
  • Area with tray and kidney containers of holding solution and instruments should have a paper lining under them
    Must make sure you have at least three holding containers- order from store.
    Cleaning important because proteinaceous material inactivates the active agent in the solution.
    If no BiB is available, may use detergent.
  • Backflow, meaning reverse flow, can occur when there is more negative pressure in the patient’s mouth than in the evacuator tubing, for example, when the patient uses the saliva ejector as a straw. When this happens, material from the mouth of a previous patient might remain in the vacuum line of the saliva ejector and be aspirated into the mouth of the next patient being treated.
    Although there have been no reports of any adverse health issues, patients should not be instructed to close their lips tightly around the saliva ejector tip during use.
    Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
  • If plastic wrap or pouches not available, may place the film in a disposable examination glove.
  • This is preferred method for clinics which have –few patients per session -take many radiographs per patient (e.g. endo clinics, comprehensive cases clinics)
    It is also good even in G.P. before an appointment for endo treatment
    Unfortunately, barriers have not been provided yet. Alternative:is next slide.
  • Now, you are left with clean gloves and a clean film packet which will not contaminate your clinic or processors
    This is the preferred technique for clinics with many patients
  • This may be done by doctor and the assistant
  • Freshly mixed
  • Impression should then be rinsed very well and immediately poured.
  • Even after disinfection, keep in mind that acrylic prostheses should be handled as if still infected because acrylic has tiny porosities which may harbor bacteria.
  • Even after disinfection, keep in mind that acrylic prostheses should be handled as if still infected because acrylic has tiny porosities which may harbor bacteria.
  • Items used between patients
    Torches may be covered with a barrier.
  • Studies have shown that colonies of microorganisms, or biofilms, can form on the inside of the small-bore plastic tubing that transports water within the dental unit to handpieces and air-water syringes. Once formed, a biofilm serves as a reservoir that may dramatically increase the number of free-floating microorganisms in water used for dental treatment.
    Most organisms isolated from dental water systems originate from the public water supply and do not pose a high risk of disease for healthy persons. Although a few pathogenic organisms, such as Legionella spp. and Pseudomonas sp., have been found, adverse public health threats have not been documented.
    Photo credit, top: CDC Image library. This Scanning Electron Micrograph depicts an E. coli (ATCC 11775) biofilm grown on PC (polycarbonate) coupons using a CDC biofilm reactor.Photo credit, bottom: Illustration from the Center for Biofilm Engineering, Bozeman MT.
  • Despite a lack of documented adverse health effects, using water of uncertain microbiological quality is inconsistent with infection control principles. Levels of contamination in water from untreated systems can exceed 1 million colony forming units per milliliter (mL) of water.
    Untreated dental units cannot reliably produce water that meets drinking water standards (fewer than 500 CFU/mL of heterotrophic water bacteria). Even using source water containing ≤500 CFU/mL of bacteria (e.g., tap, distilled, or sterile water) in a self-contained system will not eliminate bacterial contamination in treatment water if biofilms in the water system are not controlled. Removal or inactivation of dental waterline biofilms requires use of chemical germicides.
  • For this reason, CDC recommends that water used for routine dental treatment meet regulatory standards for drinking water (fewer than 500 CFU/mL of heterotrophic water bacteria).
  • infection control in orthodontics

    1. 1. Tanta University Faculty of Dentistry Orthodontic Department
    2. 2. By Mohammed Hossam Elnagar
    3. 3. Definitions          Clean Sterile Disinfect Sanitization Asepsis Disinfectant Antiseptic Static agent Universal precaution
    4. 4. Cross infection
    5. 5. Even the normal human mouth contains thousands of active microorganisms. The warm, moist conditions provide .an excellent home for all types of bacteria
    6. 6. Bloodborne Pathogens OSHA 1910.1030 Definition: Any pathogenic microorganism that is present in human blood or other potentially infectious materials (OPIM) and can infect and cause disease in persons who are exposed to blood containing the pathogen.
    7. 7. Bloodborne Pathogens Examples of bloodborne pathogens: • HIV • HBV • HCV • Herpes Virus • M. tuberculosis
    8. 8. AIDS       HIV virus suppresses the T-cells Signs and symptoms of the initial HIV infection mimic those of the flu fever, headache, diarrhea, vomiting. infection may have been carrying the disease undiagnosed for a long time HIV is transmition HIV has been isolated from saliva No cure or vaccine for AIDS
    9. 9. Viral Hepatitis TYPES OF HEPATITIS A Source of virus Route of transmission Chronic infection Prevention feces fecal-oral no B C D blood/ blood/ blood/ blood-derivedblood-derived blood-derived body fluids body fluids body fluids E feces percutaneouspercutaneous percutaneous fecal-oral permucosal permucosal permucosal yes yes yes no pre/postpre/post- blood donor pre/postensure safe exposure exposure screening; exposure drinking immunization immunization risk behavior immunization; water modification risk behavior modification
    10. 10. Average Risk of Transmission After Percutaneous Injury Risk (%) Sourc 0.3 e HIV 1.8 Hepatitis C 30.0 Hepatitis B (only HBeAg+)
    11. 11. Preventing Transmission of Bloodborne Viruses in Health-Care Settings      Promote hepatitis B vaccination Treat all blood as potentially infectious Use barriers to prevent blood contact Prevent percutaneous injuries Safely dispose of sharps and bloodcontaminated materials Prevention is Primary
    12. 12. Hepatitis B Vaccination  Effective in preventing hepatitis B • 95% develop immunity    3-dose vaccination series Test for antibodies to HBsAg 1 to 2 months after 3-dose vaccination series completed. Revaccinate for who do not develop adequate antibody response.
    13. 13. Tuberculosis Cough  Chest Pain  Coughing up blood  Weakness  Fever and/or Night Sweats  Weight loss 
    14. 14. Proper hand washing is VITAL to infection prevention Wash your hands, even if gloves have been worn:  Before and after patient contact  After contact with anything contaminated  Between contact with different patients
    15. 15. Efficacy of Hand Hygiene Preparations in Reduction of Bacteria Good Better Plain Soap Antimicrobial soap Best Alcohol-based handrub
    16. 16. Clinic Gown  The official protective gown for use in all Dental Branch clinics is the Clinic Gown • white for faculty • blue for students
    17. 17. Laboratory Gown Working in a clinical dental laboratory laboratory (yellow) gown should be used.
    18. 18. Gloves latex or Vinyl examination gloves must be worn when treating nonsurgical patients
    19. 19. Gloves Sterile disposable gloves must be worn during all surgical procedures
    20. 20. Utility Gloves heavy-duty utility gloves for cleaning , disinfecting, or handling contaminated instrument •Must be washed with antimicrobial soap, rinsed and dried •Stored in plastic bag in locker
    21. 21. Masks Masks must be worn to protect: -Face -Oral and nasal mucosa
    22. 22. Masks Masks must be changed if they become damp  The mask must be changed for each new patient, except for short exams!  If a face shield is worn it must be worn at the same time as a surgical mask 
    23. 23. Protective Eyewear Must be worn to protect from aerosol and spatter  Regular eyewear must have side shields  Side shields must be securely attached to the eyewear frame abutting the lenses and free of vents or openings 
    24. 24. Contact Surfaces
    25. 25. Cleaning Clinical Contact Surfaces  Clean and disinfect surfaces  Apply barriers
    26. 26. Blood Spill Clean up   All blood spills should be cleaned up using 10% bleach or another disinfectant The disinfectant should be allowed to soak for at least 15 minutes
    27. 27. Surface Covers Handles, handpieces or similar surfaces that may be contaminated by blood or saliva must be wrapped with clear plastic wrap
    28. 28. Computer Keyboard & Screen Barrier
    29. 29. Recapping Needles Recap anesthetic needles by using the needle recapper
    30. 30. One Handed Scoop Use the one handed scoop technique to recap if a recapper is not available
    31. 31. Sharps Used needles, blades, burs and anesthetic cartridges are to be discarded in sharps containers
    32. 32. Disposal of Contaminated Bio Waste  Any disposable items that are contaminated with blood or body fluids should be carefully handled with utility gloves and placed in a sturdy plastic red bag
    33. 33. What is Biological Waste and What is ?trash Bloody gloves Used needles Paper gowns (unsoiled) Unsoiled exam gloves
    34. 34. Critical Instruments Penetrate mucous membranes or contact bone, the bloodstream, or other normally sterile tissues (of the mouth)  Heat sterilize between uses or use sterile single-use, disposable devices  Examples include surgical instruments, scalpel blades, periodontal scalers, and surgical dental burs 
    35. 35. Semi-critical Instruments  Contact mucous membranes but do not penetrate soft tissue  Heat sterilize or high-level disinfect  Examples: Dental mouth mirrors, amalgam condensers, and dental handpieces
    36. 36. Noncritical Instruments and Devices  Contact intact skin  Clean and disinfect using a low to intermediate level disinfectant  Examples: X-ray heads, facebows, pulse oximeter, blood pressure cuff
    37. 37. Instruments must be cleaned well before sterilization
    38. 38. Instruments & Burs, Barbed Broaches and Files Clean gross deposits of materials or tissues with gauze soaked in holding solution. Soak instruments in holding solution
    39. 39. Instruments & Burs, Barbed Broaches and Files Holding Solution 1. Prevents tissues, fluids, and debris from drying. 2. Reduces the amount of viable micro-organisms during cleaning.
    40. 40. Instruments & Burs, Barbed Broaches and Files Holding Solution BiB Forte should be prepared fresh daily by diluting 50 ml / 1 litre
    41. 41. Instruments & Burs, Barbed Broaches and Files Holding Solution 1. Alcohol alone not effective for biological debris. 2. Gluteraldehyde effective but toxic. 3. Sodiumhypocloride (Clorox©) corrosive.
    42. 42. Instruments & Burs, Barbed Broaches and Files Heavy duty gloves to protect from sharp injury Scrub with brush under running water. Two sinks Washing instruments Washing hands
    43. 43. Instruments & Burs, Barbed Broaches and Files Ultrasonic cleaners 1. Reduce chances of hand injury. 2. Reduce splatter in environment 3. More effective in cleaning small crevices
    44. 44. Instruments & Burs, Barbed Broaches and Files   Rinse disinfectants from instruments well before packaging. Residue of disinfectant on instruments may cause damage upon autoclaving.
    45. 45. Hand-pieces Flush hand-piece- 1 into container for 30 seconds 4- Wipe clean 2- Lubricate hand-piece 3- Reattach handpiece and spray excess oil out by air only 5- place in envelope
    46. 46. Hand-pieces IMPORTANT To prevent damage to the hand-pieces: Always keep bur inside hand-piece when flushing it.
    47. 47. Hand-pieces DO NOT PLACE HAND-PIECES IN WATER
    48. 48. Packaging & sealing Heat sealing Sealing tape Auto-sealing
    49. 49. Packaging & sealing Double fold then tape along the edge
    50. 50. Packaging & sealing
    51. 51. Saliva Ejectors Previously suctioned fluids might be retracted into the patient’s mouth when a seal is created  Do not advise patients to close their lips tightly around the tip of the saliva ejector 
    52. 52. Infection Control During Radiograph Making
    53. 53. Spread of Contamination
    54. 54. Protect Film Packet Cover film with plastic barrier Remove film packet avoiding contaminatio .n of the film Handle clean film with new gloves.
    55. 55. Infection Control During Radiograph Making  Barrier Protection  Regloving  Two- Person Technique
    56. 56. Barrier Protection • Cover all surfaces which will be touched with plastic barrier. • Barrier should be changed between each patients
    57. 57. Re-gloving Technique 3- adjust x-ray tube and controls with clean gloves 1- Position film in patient’s mouth 2- Change gloves 4- Remove the film from the mouth 5- Remove film from wrapper. 6- discard dirty gloves and outer film wrapping.
    58. 58. Two- Person Technique Another person wearing clean gloves adjusting x-ray tube and control One person placing film in patient’s mouth The person with the dirty gloves then removes the film from the packet without contaminating the film
    59. 59. Digital Radiography  Sensor (placed in patient’s mouth)  Keyboard  X-ray tube head  Control
    60. 60. Infection Control for impressions and dental prostheses
    61. 61. The ADA recommends chemical disinfection of all impressions and dental prostheses. An acceptable disinfectant is sodium hypochlorite (Clorox© ) in a 1:10 dilution.
    62. 62. Impressions Rinse under water 15 seconds Rinse thoroughly Immerse in disinfectant 10 minutes ( keep covered or place inside bag)
    63. 63. Impressions When working with alginate, if accuracy is extremely important… Rinse-spray-rinse Rinse dipped or sprayed covered with damp paper towel for ten minutes Rinse
    64. 64. Prostheses • Most fixed and removable prostheses may be processed by rinsespray-rinse. • Unglazed porcelain should not be disinfected. The glazing process will sterilize it.
    65. 65. Prostheses Prostheses which have been worn by the patient and have gross deposits must be cleaned well before disinfection. Acrylic has tiny porosities which may harbor bacteria.
    66. 66. Other Items • Bite registration • Wax rims • Custom trays Rinse-spray-rinse
    67. 67. Casts If disinfection of a cast is indicated, immerse for 10 minutes or spray until wet and leave for 10 minutes. Cast should be fully set (at least 24 hours) before disinfection.
    68. 68. Other Prosthodontic Items Autoclave Clean and Disinfect Heat Stable Items Face-bow forks Metal impression trays All-metal spatulas s.s. bowls Non-Heat Stable Items Articulators Face-bows Wooden-handled spatulas Torches Rubber mixing bowls Shade-guides
    69. 69. Risk   Orthodontists have a high incidence of hepatitis B among dental professionals. Orthodontic procedures receives an average of about one cut per week.
    70. 70. sterilising orthodontic instruments problems : have large hinge areas that difficult to clean and sterilise  are sharp angles, cutting edges, and pointed ends that are easily damaged.
    71. 71. Pliers a Cutters  Autoclaving Usually Damage Chrome-plated pliers , Lubrication of the hings , 1.0% Sodium nitrate The chemical vapour steriliser minimal corrosion and damage to cutting edges when using this type of steriliser.
    72. 72. Convection heat more safe 
    73. 73. bands, arch wires, and brackets be sterilised in band cassettes using rapid dry heat, steam or chemical vapour sterilisation. immersed in 2% glutaraldehyde overnight  Unused chain and elastomeric ligatures be safely stored in a tackle box They may be removed with sterilised tweezers .
    74. 74. Steam autocalve
    75. 75. Chemical vapour sterilizer   Operate by heating alcohol, formaldehyde 132c for 20 min
    76. 76. Dry heat steralizer  160-170c for 1 hours
    77. 77. Rapid dry heat steralizer  Circulating air at 190c (6-12) min
    78. 78. Glass bead steralizer  218-246c for 15 sec
    79. 79. Monitoring sterilization
    80. 80. Glutaraldehyde as a Sterilant    Glutaraldehyde is no longer widely used as a sterilant in dental offices highly corrosive and toxic instruments sterilized in this manner are not wrapped
    81. 81. Dental Unit Waterlines and Biofilm Microbial biofilms form in small bore tubing of dental units  Biofilms serve as a microbial reservoir  Primary source of microorganisms is municipal water supply 
    82. 82. Dental Unit Water Quality Using water of uncertain quality is inconsistent with infection control principles  Colony counts in water from untreated systems can exceed 1,000,000 CFU/mL (CFU=colony  forming unit)  Untreated dental units cannot reliably produce water that meets drinking water standards
    83. 83. Dental Water Quality For routine dental treatment, meet regulatory standards for drinking water. <500 CFU/mL of heterotrophic water bacteria
    84. 84. Dental Unit Water Quality ICX   Available on gray cabinets at the back of the bays Instructions posted in each cubicle
    85. 85. Any Thank ? questions You