5. infection control in omfs(71) Dr. RAHUL TIWARI

INFECTION CONTROL IN OMFS
Dr. Rahul Tiwari – 2nd Yr. MDS – PG Student.
Department of Oral & Maxillofacial Surgery.
9/19/2016 RT/5/INFECTION CONTROLL IN OMFS/72 1
PRESENTING SEMINAR ON

INTRODUCTION
HISTORICAL RELEVANCE
TRANSMISSION OF INFECTION
MODE OF TRANSMISSION
INFECTION CONCERN IN OMFS
OBJECTIVES OF INFECTION CONTROL
PERSONAL BARRIER PROTECTION
EMERGENCY & EXPOSURE INCIDENT PLAN
OPERATORY ASEPSIS

DISINFECTION
INSTRUMENT HANDLING & CLEANING
STERILIZATION
MONITORS OF STERILIZATON
STORAGE OF STERILIZED ITEMS
HANDPIECE ASEPSIS
CLINICAL WASTE DISPOSAL
CONCLUSION & REFERENCES.

Introduction
4
Our bodies are
amazing structures
that defend us
against infections
under normal
circumstances.
9/19/2016 RT/5/INFECTION CONTROLL IN OMFS/72

5
Body’s Defenses
Immunity – resistant to pathogens and the
disease they cause
If defenses are not functioning properly,
person will become susceptible to invasion
and infection.
Lines of Defense
Skin
Normal flora
Staying healthy

INTRUDING BODY’S LINE OF DEFENSE
During any operative procedure, we are breaching body’s line of
defense
Sterilization , Disinfection and Asepsis
becomes important9/19/2016 RT/5/INFECTION CONTROLL IN OMFS/72 6

History of Infectious Disease
Prevention
 3,000 BC – Egyptians use antiseptics such as pitch
or tar, resins and aromatics.
 550 BC, Greek Infantry men known as hoplite
sometimes fought naked, pieces of clothing carried
into a wound by a penetrating sword or spear point
were more likely to cause infection.
 460-377 BC Hippocratus used wine or boiled
water, for asepsis.

Holmes and Sommelweis
Holmes
Demonstrated that
fever was carried
from patient to
patient by doctors.
8
Sommelweis
 Also concluded
fever was a
communicable
disease.
 The Hungerian Obstetrician Sir IGNAZ SOMMELWEIS &
OLIVER HOLMES laid down general principles of asepsis
Made hand washing compulsory before any operative procedure

Joseph Lister
9
Discovered how to use
chemical antiseptics to
control surgery related
infections
Used antiseptics to
disinfect surgical
equipment and
supplies

Joseph Lister
 Lister began washing his hands before operating, and wearing clean clothes.
 Lister also sprayed the air with carbolic acid to kill airborne germs.

 130-200 AD Galen A Greek distinguished physician boiled
instruments used in caring for wounds
 1683, Anton van Leeuwenhoek, invents the microscope and proves
the existence of microorganisms.
 1758 – the earliest recorded instance of the use of surgical glove-
Dr. Johann Julius Walbaum formed a glove from the intestines of a
sheep and used it to deliver babies
Indian connection-CHARAKA &
SUSHRUTA used Boiling Water
(Ocimum sanctum, Mangifera Indica, Neem neem)

 STERILIZATION: Use of a physical or chemical procedure to destroy
all microorganisms including substantial numbers of resistant bacterial
spores.
 Sterilization means the destruction of all life forms.
(Ronald B Luftig)
 Sterilization is the process of killing or removing all viable organisms.
(MIMS – PLAYFAIR)
Ref : C.P BAVEJA, Text book of microbiology, pg:-20-22,2nd edition, 2006
Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-4-6, 3rd edition, 2005
Ref ; Daniel M. Laskin, oral and maxillofacial surgery, pg:-346-355, vol 1, 2013

 DISINFECTION: Destruction of pathogenic and other kinds of
microorganisms by physical or chemical means. Disinfection is less lethal than
sterilization, because it destroys the majority of recognized pathogenic
microorganisms, but not necessarily all microbial forms (e.g., bacterial spores).
 Disinfection is a process of removing or killing most, but not all, viable
organisms.(MIMS-PLAYFAIR).
 Disinfection refers to the destruction of pathogenic organisms.(Ronald B
Luftig).

 DISINFECTANT: A chemical agent used on inanimate objects to destroy
virtually all recognized pathogenic microorganisms, but not necessarily all
microbial forms
(e.g., bacterial endospores).
 DECONTAMINATION: Is the process of removal of contaminating pathogenic
microorganisms from the articles by a process of sterilization or disinfection. It is
the use of physical or chemical means to remove, inactivate, or destroy living
organisms on a surface so that the organisms are no longer infectious.
ASEPSIS: Is the employment of techniques (such as usage of gloves, air filters, uv
rays etc) to achieve microbe-free environment

Antisepsis is the use of chemicals (antiseptics) to make skin or mucus
membranes devoid of pathogenic microorganisms.
Bacteriostasis is a condition where the multiplication of the bacteria
is inhibited without killing them.
Bactericidal is that chemical that can kill or inactivate bacteria. Such
chemicals may be called variously depending on the spectrum of
activity, such as bactericidal, virucidal, fungicidal, microbicidal,
sporicidal, tuberculocidal or germicidal.

 Infection transmission during dental procedures is dependent on four
factors:
1. Source of infection – may be a patient or a member of the dental team
who is suffering from, or is a carrier of an infectious disease.
SOURCE
16
Patients suffering from acute
infection
Patients in prodromal
stage
carriers
known unknown
Ref ; C.P.Baveja, text book of microbiology, 2nd edition, pg:-49-50, 2006
Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-33-35 , 3rd edition, 2005

2. Means of transmission – Micro organisms capable of causing disease
are present in human blood and saliva. Contact with blood or saliva
may transmit such pathogenic organisms causing infection.
3. Route of transmission – Transmission may occur due to inhalation or
inoculation.
4. Susceptible host – Is a person who lacks effective resistance to a
particular micro organism. E.g immuno compromised patients,
pregnant women and children.
17
Ref ; C.P.Baveja, text book of microbiology, 2nd edition, pg:-49-50, 2006
Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-33-35 , 3rd edition, 2005

NOSOCOMIAL INFECTIONS
 Hospital acquired infections
 Study on efficacy of NI control projected by US CDC in 1970 to reduce NI and it
results approx. 32% reduction in NI in hospitals and health care units.

Screening
PPE
Aseptic techniques
Sterilization &
disinfection
disposal
Laboratory asepsis9/19/2016 RT/5/INFECTION CONTROLL IN OMFS/72 19

Personal protective equipment (PPE), or barrier precautions, are a major
component of Standard precautions.
PPE is essential to protect the skin and the mucous membranes of
personnel from exposure to infectious or potentially infectious materials.
The various barriers are gloves, masks, protective eye wear, surgical
head cap, foot wear & overgarments
20

 All clinical personnel must wear treatment gloves during all
procedures.
 Types:
1. Latex gloves
2. Vinyl gloves
3. Nitile gloves
4. General purpose
utility gloves
21
Ref : Chitra Chakravathy, textbook of oral & maxillofacial surgery, pg:-12-13 ,2nd edition,2011

22
Gown type Situation and Rationale
Cotton/linen, reusable or disposable,
long-sleeved isolation gowns
Use if contamination of uniform or
clothing is likely or anticipated
Fluid resistant isolation gown or plastic
apron over isolation gown
Use if contamination of uniform or
clothing from significant volumes of
blood or body fluids is likely or
anticipated (fluids may wick through
non-fluid resistant reusable or disposable
isolation gowns)
impervious gowns e.g., Gortex® Fluid Use if extended contact or large volume
exposure (e.g., large volume blood loss
during resuscitation of MVA victim or
surgical assist)
Ref : Chitra Chakravathy, textbook of oral & maxillofacial surgery, pg:-12-13 ,2nd edition,20119/19/2016 RT/5/INFECTION CONTROLL IN OMFS/72

23

Ref ; Daniel M. Laskin, oral and maxillofacial surgery, pg:-346-355, vol 1, 20139/19/2016 RT/5/INFECTION CONTROLL IN OMFS/72

 Management of exposure includes:
A. General wound care and cleaning.
B. Counseling of the exposed worker regarding blood borne pathogens.
C. Source patient testing for HBV,HCV and HIV (consent required).
D. Documentation of the incident and review.
E. Post exposure assessment and prophylaxis for the health care worker.
F. Baseline and follow up serology of the worker.
24
Ref : Neelima malik, textbook of oral & maxillofacial surgery, pg:-70-101 ,2nd edition,2011

 CHLORHEXIDINE BASED – these contain 2- 4% chlorhexidine gluconate with 4%
isopropyl alcohol in a detergent solution with a pH of 5.0 to 6.5. They have broader
activity for special cleansing(e.g: for surgery, glove leaks, or when clinician
experiences injury). But it can be hazardous to eyes.
 POVIDONE IODONE – contain 7.5-10% povidone iodine, used as a surgical hand
scrub.
 PARACHLOROMETEXYLENOL(PCMX) – these are bactericidal and fungicidal
with 2% concentration. Non irritating and recommended for routine use.
 ALCOHOL HAND RUBS- ethyl alcohol and isopropyl alcohol are widely used at
70% concentration. They are rapidly germicidal when applied to the skin.
25
Ref : Chitra Chakravathy, textbook of oral & maxillofacial surgery, pg:-12-13 ,2nd edition,2011

LEVEL SPECTRUM USE EXAMPLES
Low level Bacteria except
mycobacteria not
spores.
Some fungi and
some
Viruses.
Surfaces without
blood
Quaternary
ammoniums, some
phenolics,
some iodofors
Intermediate
level
Mycobacteria, not
spores.
Most fungi and
most viruses.
Surfaces with
blood
Quaternary
ammoniums with
alcohol, chlorines,
phenolics, iodofors
High level All microbes except
spores
Immersion Glutaraldehyde,
strong peroxides,
ophthaldehyde
Ref: Cohen: Pathways of the Pulp, 9th Edition pg:-1-9,2007

Ref: Cohen: Pathways of the Pulp, 9th Edition
pg:-1-9,2007

Steam sterilization cellulose, cotton/polyester cloths, window packs,
perforated rigid containers with bacterial filters, glass
containers for liquids
Dry heat (hot air oven) Metal canisters and tubes of aluminium foil, glass
tubes, bottles
ETO Paper & Plastic, perforated rigid containers with
bacterial filters
Low temperature steam Paper, cloth
Radiation sterilization Polyethylene, PVC, polypropylene, foil.

Ultrasonic cleaning is the safest and most efficient way to clean sharp
instruments.
An ultrasonic cleaning device should provide fast and thorough
cleaning without damage to instruments; have a lid, well-designed
basket, and audible timer; and be engineered to prevent electronic
interference with other electronic equipment

Physical agents:
1. Sunlight
2. Drying
3. Dryheat: flaming, incineration,
hot air
4. Moist heat: pasteurization,
boiling, steam under pressure,
steam under normal pressure.
5. Filtration: candles asbestos
pads, membranes
6. Radiation
7. Ultrasonic and sonic vibrations
Chemical agents:
1. Alcohols: ethyl, isopropyl,
trichlorobutanol
2. Aldehydes: formaldehyde,
glutaraldehyde
3. Dyes
4. Halogens
5. Phenols
6. Surface-active agents
7. Metallic salts
8. Gases: ethylene oxide, formaldehyde,
beta propiolactone.9/19/2016 RT/5/INFECTION CONTROLL IN OMFS/72 31

The four accepted methods of sterilization are :
A. Steam pressure sterilization (autoclave)
B. Chemical vapor pressure sterilization- (chemiclave)
C. Dry heat sterilization (dryclave)
D. Ethylene oxide sterilization

Advantages of Autoclaves.
Autoclaving is the most rapid and effective method for
sterilizing cloth surgical packs and towel packs.
Is dependable and economical
Sterilization is verifiable.

Disadvantages of Autoclaves.
Items sensitive to the elevated temperature cannot be autoclaved.
Autoclaving tends to rust carbon steel instruments and burs.
Instruments must be air dried at completion of cycle.

Advantages
1. Carbon steel and other
corrosion-sensitive
instruments are said to be
sterilized without rust.
2. Relatively quick turnaround
time for instruments.
3. Load comes out dry.
4. Sterilization is verifiable.
Disadvantages
1. Items sensitive to the
elevated temperature will
be damaged. Vapor odor
is offensive, requires
aeration.
2. Heavy cloth wrappings of
surgical instruments may
not be penetrated to
provide sterilization.

Conventional Dry Heat Ovens
Short-Cycle, High-Temperature
Dry Heat Ovens

Advantages
1. Carbon steel instruments and
burs do not rust, corrode, if they
are well dried before
processing.
2. Industrial forced-draft hot air
ovens usually provide a larger
capacity at a reasonable price.
3. Rapid cycles are possible at
high temperatures.
4. Low initial cost and sterilization
is verifiable.
Disadvantages
1. High temperatures may damage
more heat-sensitive items, such
as- rubber or plastic goods.
2. Sterilization cycles are
prolonged at the lower
temperatures.
3. Must be calibrated and
monitored

METHOD TEMPERATURE(ºc) HOLDING TIME(MINS)
AUTOCLAVE 121 15
126 10
134 3
HOT AIR OVEN 160 45
170 18
180 7.5
190 1.5

MOBILE FUMIGATOR

Advantages:
1. Operates effectively at
low temperatures
2. Gas is extremely
penetrative
3. Can be used for sensitive
equipment like
handpieces.
4. Sterilization is verifiable
Disadvantages:
1. Potentially mutagenic
and carcinogenic.
2. Requires aeration
chamber ,cycle time lasts
hours
3. Usually only hospital
based.

Gamma radiation
Dry-Heat Sterilizers
Liquid Chemicals
Performic Acid
Filtration
Microwave
U.V radiation
Flash sterilization
Glass Bead “Sterilizer”
Vaporized Hydrogen Peroxide
Formaldehyde Steam
Gaseous Chlorine Dioxide
Vaporized Peracetic Acid
Infrared radiation
Oxygen plasma sterilization

Ozone sterilization is the newest low-
temperature sterilization method recently
introduced in the US and is suitable for
many heat sensitive and moisture sensitive
or moisture stable medical devices
Ozone sterilization is compatible with
stainless steel instruments.
Ozone Parameters • The cycle time is
approximately 4.5 hours, at a temperature
of 850F – 940F.

 Various new methods of sterilization are under investigation and
development.
1. Peroxide vapor sterilization - an aqueous hydrogen peroxide solution
boils in a heated vaporizer and then flows as a vapor into a sterilization
chamber containing a load of instruments at low pressure and low
temperature
2. Ultraviolet light - exposes the contaminants with a lethal dose of
energy in the form of light. The UV light will alter the DNA of the
pathogens. Not effective against RNA viruses like HIV.
Product made with antimicrobial copper alloy (brases & bronzes) destrots a wide range of
organism in a short period of time. US environment protection agency has approved this.

NEWER TECHNIQUES
 Electrospun Poly(lactic acid) (PLA) Fiber Alignment for
Biomedical Applications
 New disinfection methods include a persistent antimicrobial
coating that can be applied to inanimate and animate objects
(Surfacine), a high-level disinfectant with reduced exposure
time (orthophthalaldehyde), and an antimicrobial agent that
can be applied to animate and inanimate objects
(superoxidized water).
 New sterilization methods include a chemical sterilization
process for endoscopes that integrates cleaning (Endoclens), a
rapid (4-hour) readout biological indicator for ethylene oxide
sterilization (Attest), and a hydrogen peroxide plasma sterilizer
that has a shorter cycle time and improved efficacy

Ref : Cross infection control, journal of dental nursing, pg:-392-397, vol 9, no.7, july 2013

Surgical hand piece sterilization

Should Do
Remove bur and disconnect handpiece from
chair.
Wipe handpiece with alcohol.
Locate appropriate hole and spray lube for 2-3
seconds.
Attach handpiece to swivel unit and insert bur.
Run handpiece for 30 seconds to eliminate lube.
Wipe handpiece with alcohol.

Should Do
Insert in autoclave bag…….paper on at least
one side of bag.
Load in autoclave with cellophane side down.
Remove from autoclave immediately after all
cycles are complete.
Always allow cooling to room temperature,
paper side up.
Do not force cool with water or other means.

Should not do
Do not immerse hand piece in any solvent,
cleaner or ultrasonic solution.
Do not clean hand piece in ultrasonic
cleaners or dry heat sterilizers.
Do not exceed temperature of 135°C.
Do not use chemical disinfectants, when
combined with heat of the autoclave,
disinfectants may significantly reduce hand
piece life
Do not use all cellophane bags

Important points to remember
1) The patient is the center of the sterile field.
2) Keep hands at waist level and in sight at all times.
3) Keep hands away from the face.
4) Never fold hands under arms.
5) Gowns are considered sterile in front from chest to level of sterile
field, and the sleeves from above the elbow to cuffs. Gloves are sterile.
6) Sit only if sitting for entire procedure.

THE THEATRE

National Accreditation Board for Hospitals and
Healthcare Providers
 OT Size: Standard OT size of 20’ x 20’ x 10’
 Occupancy: Standard occupancy of 5-8 persons
at any given point
 Non adherent ,nonporous surfaces- OT WALL CLADINGS
 Rounded corners

AIR QUALITY
 Air Filtration: The air quality at the supply i.e. at grille level should be Class 1000
 Class 1000 means a cubic foot of air must have no more than 1000 particles

 1. Only sterile items are used within the sterile field
 2. Sterile persons are gowned and gloved
 3. Tables are sterile only at table level
 4. Sterile persons touch only sterile items or areas
 5. Unsterile persons avoid reaching over the sterile field
 6. The edges of anything that encloses sterile contents are considered unsterile
 7.The sterile field is created as close as possible to the time of use
 8. Sterile areas are continuously kept in view
 9. Sterile persons keep well within the sterile area
 10. Break of the integrity of microbial barriers results in contamination

Preoperative showering with hexachlorophene
has shown reduction in wound infection.
Short preoperative hospital stay reduces
pathogenic bacteria on skin and nasal carrier
state.

Pre-operative hair removal
 Shaving a patient’s skin before surgery may raise
the risk of an infection.
 In its guidelines for preventing surgical site
infections, the Centre for Disease Control
recommends that hair should not be removed
unless it will interfere with the operation.
 When shaving is necessary, electrical clippers
should be used.
 Preferably immediately before surgery
 Shaving with a razor blade causes microscopic
nicks in the skin that can become bacterial breeding
grounds.

 Before the skin preparation of a patient is initiated, the skin should
be free of gross contamination (i.e., dirt, soil, or any other debris)
 The patient’s skin is prepared by applying an antiseptic in
concentric circles, beginning in the area of the proposed incision
and medial to lateral.
 The prepared area should be large enough to extend the incision or
create new incisions or drain sites
Patient skin preparation

DRAPING THE PATIENT
Turban draping
Commercially available drapes

Wet your hands, apply a little soap or forearms to 5cm above your
elbows for one complete minute

Gowning

Gloving

68
Hazardous Waste management
Hazardous waste products include:
Blood and blood products
Body fluids and tissue
Cultures
Vaccines
Sharps
Gloves
Specula
Inoculating loops
Paper product contaminated with body fluids

69
YELLOW BAG RED BAG BLUE BAG BLACK BAG ORANGE BAG
•Human anatomical
waste
•Animal waste
•Microbiology and
biotechnology
waste
•Solid waste( items
contaminated with
body fluids)
•Microbiology and
biotechnology
waste
•Solid waste
(tubings, iv
catheters)
•Waste sharps
•Solid waste
(tubings, iv
catheters)
•Discarded
medicines and
cytotoxic drugs
•Incineration ash
•Chemicals used in
disinfection &
insecticides
• Animal and
slaughter house
waste
Ref. Guidelines on HIV testing, National AIDS Control Organization (NACO), march 2007, pg :-32
Ref. Preventive and social medicine, K.PARK, pg.738-739, 22nd edition, 2013

CONCLUSION & REFERENCES
“Strictly following the protocols of
sterilization & disinfection will results in
high success rate and decrease in surgical
infections & postoperative complications ”
1. Anantnarayan-Textbook of Microbiology
2. LJ Peterson-Cotemporary Oral & Maxillofacial Surgery
3. Laskin-Textbook of Oral & Maxillofacial Surgery
4. Fonseca-vol-2, edition 3

“There Is No Compromise with Sterility
It’s either Sterile or Unsterile.”
Take home message…….


5. infection control in omfs(71) Dr. RAHUL TIWARI

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