Chapter 15: Infection Control and the Dental Radiographer

The Recommended infection control practices that directly relate to dental radiography procedures include the following

-PPE -Handwashing and care of hands -Sterilization or disinfection of instruments -Cleaning and disinfection of dental unit and environmental surfaces

Patient Preparation

-Remove any artifacts that may be in the path of x-ray: partials, dentures, jewelry, glasses, etc -Patient consent form = signed by patient -RMH, vitals, EO/IO = Signed by Dr or instructor -Lead-apron and thyroid collar

Beam Alignment Devies

-Should be packaged in sterilized bags and dispensed from a central supply area

Pathogen

A microorganism capable of causing disease -Cold and flu viruses and bacteria -Cytomegalovirus (CMV) -HBV, HCV -Herpes simplex virus -HIV

Exposure incidient

A specific incident that involves contact with blood or other potentially infectious materials and that results from procedures performed by the dental professional.

Antiseptic

A substance that inhibits the growth of bacteria. This term is often used to describe handwashing or wound-cleansing procedures.

Critical instrument

Instruments that are used to penetrate soft tissue or bone are considered this and must be sterilized after each use. -Examples include forceps, scalpels, bone chisels, scalers, and surgical burs -In dental radiography, no critical instruments are used

Semicritical instrument

Instruments that contact but do not penetrate soft tissue or bone are classified as this. These devices must also be sterilized after each use -If the instrument can be damaged by heat and sterilization is not feasible, high-level disinfection is required. -Beam alignment devices are an example of this type of instrument used in dental radiography

Sterilzation

Total destruction of spores and disease producing microorganisms 1. Steam under pressure 2. Dry heat process 3. Heat/Chemical vapor 4. EPA-registered high-level disinfecant

Intermediate-level Disinfectant

U.S. Environmental Protection Agency (EPA)-registered chemical germicides labeled as both "hospital disinfectants" and "tuberculocidals"; recommended for all surfaces that have been contaminated.

Low-Level disinfectant

U.S. Environmental Protection Agency (EPA)-registered chemical germicides labeled only as "hospital disinfectants"; recommended for general housekeeping purposes.

Disinfect

Use of a chemical or physical procedure to inhibit or destroy pathogens. Highly resistant bacterial and mycotic (fungal) spores are not killed during disinfection procedures

X-ray machine

-The tubehead, PID, control panel, and exposure button must al be covered or disinfected

Purpose of Infection Control-->*Chain of infection*

1. Susceptible host 2. Pathogen 3. Sufficient number of pathogens to initiate infection 4. Portal of entry

Sharps

Any objects that can penetrate the skin, including, but not limited to , needles and scalpels.

Occupational exposure

Contact with blood or other infectious materials that involves the skin, eye, or mucous memebrane

Lead Apron

If contaminated, must be wiped with a disinfectant between patients.

Barrier envelope

Intraoral films may be inserted and sealed in plastic barriers also called this.

Bloodborne pathogens

Pathogens present in blood that cause diseases in humans

Infectious waste

Waste that consists of blood, blood products, contaminated sharps, or other microbiologic producs

Guidelines for infection control and government agencies:

*CDC* - Influence in development and recommendations *OSHA* - enforces regulation *FDA* - regulation of waste products, chemicals, disinfectants

Purpose of Infection Control

*Pathogen* - A microorganism capable of causing disease *AIDS* - Acquired immunodeficiency syndrome *HIV* - Human immunodeficiency virus *Viral Hepatitis* - especially Hep C *TB* - Tuberculosis *Herpes Virus*

Guidelines for infection control

*Standard Precautions* - A practice of care to protect persons from pathogens spread via blood or any other body fluid, excretion or secretion *except sweat*, *More inclusive* *Universal Precautions* - Concept of infection control where the focus was on blood-born pathogens *The all inclusive* - "Standard Precautions" has replaced this concept

Guidelines for infection control

*Standard Precautions* - all body fluids, except sweat, are assumed to be infected, whether infected or not -Guidelines for infection control are regulated, recommended, reinforced, developed by govrenment agencies

For an infection to occur by one these routes of transmission, the following 3 conditions must be present.

-A susceptible host -A pathogen with sufficient infectivity and numbers to cause infection -A portal through which the pathogen may enter the host *Effective infection control practices are intended to alter one of these 3 conditions, thereby preventing disease transmission*

Protective Clothing

-All dental professionals must wear protective clothing (gown, lab coat, uniform) to prevent skin and mucous membrane exposure when contact with blood or other body fluids is anticipated -Must be changed daily or changed more frequently if it is visibly soiled -Must be removed before leaving the dental office, and the should be laundered.

Sterilization and Disinfection of Instruments

-All instruments in the dental practice can be classified into tone of the following categories, depending on the risk of transmitting infection and the need to sterilize the instrument between uses: -Critical Instruments -Semicritical Instruments -Noncritical instruments

Disinfection

-Chemical applications that reduce disease producing microorganisms to an acceptable level -Too toxic for living tissues -*all spores are not necessarily killed* -Use on inanimate objects, x-ray control panel, dials or exposure buttons and on some object that can't be heat sterilized

Preparation of Supplies and Equipment

-Clinician must also have ready all anticipated supplies and equipment, such as film, sensors, sterilized beam alignment devices, and other misc. items and must make these available in the work area

Operatory Preparation

-Cover the treatment area with barrier prior to x-ray exposure -Including computer key board and any device you might use

Care of Hands

-Dental professionals with exudative or "weeping" lesions on their hands must refrain from all direct patient contact and from handling patent care equipment until the condition has resolved

In the dental environment, the general routes of disease transmission can be described as follows:

-Direct contact with pathogens present in saliva, blood, respiratory secretions, or lesions -Indirect contact with contaminated objects or instruments -Direct contact with airborne contaminated present in spatter or aerosols of oral and respiratory fluids

Hand Hygiene

-General term that applies to routine hand-washing, antiseptic hand-wash, and antiseptic hand-rub techniques -Indications for hand hygiene include: •Before and after treating each patient (e.g., before glove placement and after glove removal) •After removing gloves that are torn, cut, or punctured and before putting on new gloves •After contact of bare hands with inanimate objects likely to be contaminated by blood, saliva, or respiratory secretions •Before leaving the dental operatory •When hands are visibly soiled or contaminated

Introduction

-In 2003, the CDC released a publication entitled guidelines for infection control in dental health care settings, which provides updated infection control practices for dentistry. -The recommended infection control practices are applicable to all settings in which dental treatment is provided

Infection Control For Radiographic Procedures

-Infection Control Procedures Used Before Exposure -Infection Control Procedures Used During Exposure -Infection Control Procedures Used After Exposure -Infection Control Procedures Used for Processing

Noncritical instrument

-Instruments or devices that do not come in contact with mucous membranes are considered this -Because little risk of transmitting infection from noncritical devices exists, intermediate-level or low-level infection techniques are required for their care between patients -Examples in dental radiography include the position-indicating device (PID) of the dental x-ray tubehead, the exposure button, the x-ray control panel, and the lead apron.

Image receptors preparation

-Intraoral dental image receptors not needed to be sterile = "Industrially clean" -Use barrier envelopes according to the size and seal the envelopes properly -Avoid cross-contamination

Standard precaustions

-Measures that include a standard of care designed to protect health care personnel and patients from pathogens that can be spread by blood or any other body fluid, excretion, or secretion. -The same infection control procedures must be used for each patient. No exceptions exist, and no "extra" precautions should be used on any patients -Specific infection control procedures pertain to dental radiography and must be used for each patient

Gloves

-Must wear medical latex or vinyl gloves to prevent skin contact with blood, saliva, or mucous membranes -New gloves for each new patient -When touching contaminated items or surfaces -Nonsterile gloves are recommended for examinations and nonsurgical procedures; steril gloves are recommended for all surgical procedures. -Must be removed and discarded when exiting the pt. treatment area and wash hands immediately -Must always wash hands and put on new gloves between patients -Removed and changed whenever they are torn,cut, or punctured -Never washed before use or disinfected for reuse, as this causes defects and diminishes the barrier protection

Noncritical instruments

-Objects or surfaces that do not come into contact with the mucous membranes but maybe contaminated with spatter or aerosois -Ex: Lead apron, thyroid collar, PID, etc (can use disinfectants)

Disinfection and Sterilization

-One-step disinfectant that kills a wide range of pathogens in one minute -Bactericidal, Tuberculocidal, Virucidal, Fungicidal, herbicidal -Dual chain quaternary ammonium/high level alcohol solution

Personal protective Equipment (PPE)

Includes protective attire, gloves, mask, and eyewear

Preparation of Treatment Area

-Surfaces that are likely to be touched during the radiographic procedure must be prepared by the clinician -Covered with impervious, disposable materials such as plastic wrap, plastic-backed paper, or aluminum foil. -If disposable materials are not used, after the radiographic procedures have been completed, all contaminated areas must be disinfected with disinfecting products, following the manufacturer's instructions -Examples of surfaces that must be covered or disinfected include the following: X-ray machine, dental chair, work area, lead apron,

Purpose of Infection Control

-The purpose of infection control procedures used in oral health care is to prevent the transmission of disease among pt's and between pt's and oral health care practitioners. -The specific steps of these protocols require practice to achieve competency in skilled handling of contamination radiographic equipment and supplies.

Digital Sensors

-The sensors/receptors used cannot be eat sterilized, so in order to avoid cross-contamination, both barrier techniques and disinfection are required -CDC recommends cleaning and disinfecting the sensor with an EPA-registered intermediate-level disinfectant after removing the barrier and before using it another pt. -These sensors must be wrapped in plastic barrier envelopes to protect the sensor from salvia and contamination, much like the barriers used for intraoral films

Acceptable methods of Sterilization

-These include steam under pressure or autoclave, dry heat, and chemical vapor. -Proper functioning of sterilization cycles must be verified by periodic use of a biologic indicator, such as the spore test

Semi-Critical Instruments

-Those that contact oral mucosa without penetrating soft tissue or bone -Ex: Mouth mirror, image receptors holding device, etc - needs to be sterilized or discarded

Critical Instruments

-Those that penetrate soft tissue or bone. -Ex: Scalers, probes, etc (not used in taking radiographs)

Purpose of Infection Control

-To protect and prevent the transmission of infectious diseases to and from -May be transmitted from: ~Patient to dental professional ~Dental professional to patient ~Pt. to Pt.

DisCide Ultra Disinfecting Wipes - Kills all listed pathogens in one minute

-Tuberculosis bacteria -Staphylococcus aureus -Pseudomonas aeruginosa -Salmonella enterica -Escherichia coli -Avian influenza A virus -Herpes Simples Virus type 2 -Candida albicans -Proteus mirabilis -MRSA -VRE -HBV, HCV, RSV -Pandemic 2009 H1N1

Masks and Protective Eyewear

-Whenever spatter and aerosolized sprays of blood and saliva are likely, all dental professionals must use these -Must be changed between patients or during treatment if it becomes wet or moist. -After treatment face shields and protective eyewear must be washed with appropriate cleaning agents

*EPA-Registered Disinfectants Classification*

1. *High-level disinfectant* - germicidal, inactivate spores 2. *Intermediate-level disinfectant* - germicidal, hospital grade and tuberculocidals, iodophors, phenolics, chlorine containing compounds. *does not destroy spores* 3. *Low-level disinfectant* - hospital grade disinfectants. Cannot destroy spores, tubercle bacili, or non lipid viruses

Classification of objects used in radiographic procedures

1. Critical instruments 2. Semi-Critical instruments 3. Noncritical instruments

Purpose of Infection Control-->*Rout of infection Transmission*

1. Direct contact with pathogen 2. Direct contact with airborne contaminates 3. Indirect contact with contaminated objects, instruments

Chain of Infection -->*Prevention*

1. Immunization - CDC recommendation for vaccination: HVB, influenza, measles, mumps, rubella, and tetanus 2. Sterilization and protective barriers 3. PPE 4. Rigid infection control - reduce the numbers of pathogens

Infection Control for film Automatic Processor

1. Intraoral film is protected by outer wrapping 2. Open daylight loader lid and place contaminated film in a cup - Close the lid - put dry hands through the sleeves - put gloves on inside the daylight loader with lid closed 3. Open up outer wrapping and remove film without contaminating film, place the film in the other cup 4. Once all film packets are opened, remove contaminated gloves and then load film with dry, clean hands into the automatic processor.

Infection Control for radiographic procedures

1. Operatory preparation 2. Image receptors preparation 3. Patient preparation

PPE

1. Protective clothing 2. Masks 3. Protective Eyewear 4. Gloves -*Handwashing* - all jewelry, including watch and rings, should be removed prior to hand washing -Long fingernails, false fingernails, nail polish should be avoided, as these may harbor pathogens and have the potential to puncture treatment gloves

Infection Control for Radiographic Procedures For PSP Plates

1. Seal the PSP plates with plastic barrier envelopes and place them on a separate clean try with barriers - from receptor holding pink tray to blue tray for a pt. 2. Disinfect the PSP plates after x-ray image is recorded, place the exposed phosphor plates on top of paper towel to soak up the excess saliva. Upon completion of x-ray exposure, wipe the barriers with DisCide to prevent cross-contamination

Infection Control for Radiographic Procedures For PSP Plates

3. Remove plastic barrier from the image receptor by opening without contaminating PSP plate, The image receptors are placed in light tight black box 4. Once all plates are placed in light tight box, remove the contaminated gloves. Without gloves, carry the black light-tight box into the processing room to scan the image. 5. Put on a new gloves, insert the sensors into the slot of the scanning carrousel to be processed by the laser scanner.

Infection Control for Radiographic Procedures For PSP Plates

6. If phosphor plate is contaminated, use ethyl alcohol on soft 4x4 gauze to disinfectant the phosphor plate with gentle circular motion to prevent scratching the surface 7. Deactivate the phosphor plate on the view box for 5 min. prior to replacing on the tray for the next operator

Film

Dental x-ray films should be dispensed from a central supply area in a disposable container

Parenteral Exposure

Exposure to blood or other infectious materials that results from piercing or puncturing the skin barrier (Needle-stick injury results in parenteral exposure)

Misc. items

Other items include cotton rolls that can be used to stabilize receptor placement and paper towels hat can be used to remove saliva from exposed receptors. -A disposable container (cup or bag) labeled with the Pt's name is necessary to collect the exposed receptors -All of these items should be dispensed from a central supply area

High-level Disinfectant

The US Environmental Protection Agency (EPA) has classified certain chemicals as "sterilants-disinfectants." These EPA registered chemicals are classified as this type of disinfectant and can be used to disinfect heat-sensitive semicritical dental instruments

Asepsis

The absence of pathogens, or disease-causing microorganisms. This term is often used to describe procedures that prevent infection (aseptic technique)

Disinfection

The act of disinfecting

Sterilization

The act of sterilizing

Work area

The area where x-ray supplies, or film sensors, are placed during exposure must be covered or dsinfected

Dental Chair

The headrest as well as the headrest adjustment and chair adjustment controls must be covered or disinfected

Sterilize

The use of a physical or chemical procedure to destroy all pathogens, including highly resistant bacteria and mycotic spores

In dental radiography, 3 different types of had hygiene may be practices:

•Routine hand wash: Water and nonantimicrobial soap (i.e., plain soap) for 15 seconds •Antiseptic hand wash: Water and antimicrobial soap (e.g., chlorhexidine, iodine and iodophors, chloroxylenol [PCMX], triclosan) for 15 seconds •Antiseptic hand rub: Alcohol-based product until the hands are dry