DENTAL TRIBUNE Asia Pacific Edition No. 6/2014 Special: Practice Hygiene 7

Infection control has never beenmore essentialAn update on practice hygiene measures and protocolsDr Safura BaharinMalaysia

Demand for dental treatmenthas been increasing in recentyears as people have becomemore aware of their oral health and the benefits of gooddental aesthetics. Maintaining and practising stringent cross-infection control procedurestherefore have never beenmore essential to ensure thehealth and safety of dentists,dental hygienists and assis-tants, as well as other support-ing staff who may be indirect-ly involved in the treatmentprocess.

Dental professionals are athigh risk of cross-infection. A report published in 1999 hasshown that in developing coun-tries, for example, the number ofdental staff contaminated duringtreatment is increasing by almost 6 per cent each year.1 Researchhas shown that infectious micro-organisms can be transmitted by blood or saliva via direct or indirect contact, aerosols, or contaminated instruments andequipment.2 As stated by the USCenters for Disease Control andPrevention (CDC) in their 2003guidelines, the transmission ofinfectious disease can occur infour ways: direct contact withblood or body fluids, indirectcontact with contaminated ob-jects or surfaces, contact withbacterial droplets or aerosols,and inhalation of airborne micro-organisms.3

The most likely mode of trans-mission in dentistry is throughinhalation of bacterial aerosolsor splatters. Their potentialhealth hazards are well docu-mented and acknowledged.49

Both can be host to a large varietyof micro-organisms and viruses,which can be infectious to susceptible individuals. Duringtreatment, the dentists face andpatients chest are most affectedby splatter, as the majority of thesplatters are radiated towardsthem.10, 11 According to studies,the most contaminated area onthe dentists face during treat-ment is around the nose and inner corner of the eyes.11

Splatter consists of large par-ticles of greater than 100 m

generated during the use of den-tal equipment, such as turbines,ultrasonic scalers, or water andair syringes. Owing to this, splat-ter tends to travel in a trajectory,thereby contacting objects in itspath. Aerosol consists of smallerparticles that can remain in the air for a long time and travelwith air currents. Most dentalaerosols are less than 5 m in diameter; therefore, they areable to penetrate and stay withinthe lung, causing respiratory orother health problems. Amongdental procedures that producehigh aerosol concentration areultrasonic scaling, tooth prepa-ration using high-speed hand-pieces, and dental extraction involving bone removal via adental handpiece.8

The World Health Organiza-tion (WHO) has reported a rise inairborne infections worldwide.Tuberculosis in particular has in-creased in the developing world(Tab. 1).12 It has been stipulatedthat the risk of exposure to tuber-culosis in susceptible DHCP isgreater than in healthy individu-als. Bennett et al. concluded thatdentists and their assistants, whoare exposed for approximately 15 minutes during peak aerosolconcentration, have a slightlyhigher risk of exposure to Myco -bacterium tuberculosis than thegeneral public does.9During this

period, the DHCP inhales about0.014 to 0.12 l of aerosolisedsaliva, which may contain viablepathogens that can have a detri-mental effect on the health of susceptible DHCP.

With all of this in mind, it is theresponsibility of DHCP to adherestrictly to recommended infec-tion control guidelines and po -licies. Several measures should be taken to reduce and controlairborne contamination in thedental clinic. For example, it hasbeen demonstrated that the useof a mouthrinse, high-volumeevacuation or a combination ofboth methods significantly re-duces the number of colony-forming units in aerosols emittedduring ultrasonic scaling.13 Rou-tine use of rubber dam isolationprovides a clean and dry area forplacement of dental restorations,

page 8DT

Country Estimated # of cases Estimated rate(per 100,000 population)

Pakistan 410,000 231

Bangladesh 350,000 225

Indonesia 450,000 185

India 2,200,000 176

Myanmar 200,000 377

Malaysia 24,000 80

Thailand 80,000 119

Table 1:Tuberculosis in Asia.12

During treatment the most contaminated areas are around the dentists nose and his or her inner corner of the eye.

(DTI/P

hoto Ja

smin M

erdan)

PPE Recommendations Rationale

Surgical mask Should cover both nose and mouth Splatters and aerosols may contain bacteria

Change when wet (from sweating, and viruses that can infect a susceptible

sneezing, breathing or other contamination) person in the dental clinic.

Use particulate filter respirators (N95) To protect dentists and assistants oral and

when airborne isolation precautions are nasal mucosa from blood and saliva splatter

necessary (transmission-based precautions Some of these micro-organisms are small

for patients with tuberculosis) enough to penetrate the mask and are then

then inhaled by the DHCP and infect

the lungs. A special mask may therefore

be needed (N95 and FFP3 respirators).

Protective eyewear Should be worn all the time Splatters from dental procedures may come

Preferably with lateral protection that is into contact with the conjunctiva

wide enough to cover the eye and cause irritation or infection.

Must be rinsed and disinfected when Some materials used during dental

contaminated between patients treatment, such as sodium hypochlorite,

may cause severe irritation and damage

if accidentally splashed into

the DHCPs eyes or face.

To protect the mucosa of the eyes

from splatters

Face shield/visor Select a face visor with acceptable Splashes or splatters generated during

visual quality (clear, no reflection or refraction) dental treatment, especially when using an

and no fogging ultrasonic scaler or high-speed handpiece,

are concentrated towards the dentists face.

Wearing a face shield also reduces the amount

of splatter contaminating the face area.

To protect the face from splatters and

aerosols during dental procedures

Gloves Worn when in contact with blood or body fluids To prevent transmission of infection

Double gloving may reduce the risk from the patient to the DHCP and vice versa

of exposure in high-risk patients To prevent the contact of blood and saliva

(HIV, hepatitis B or C virus) with the dentists hands

Should be worn for the duration of the dental

treatment and changed between patients

Hands must be washed before wearing gloves

Protective clothing, Change daily or when visibly contaminated To protect daily clothing from

such as gowns with blood or oral fluids contamination from splatter or aerosols

or jackets Wash separately from domestic High occurrence of blood-contaminated

and non-medical clothing splashing in the direction of the

dentist during surgical procedures

Preferably long sleeves with a tight cuff Areas commonly contaminated are the

right forearm, abdomen and thorax8

Table 2:Recommendations and rationale concerning personal protective equipment.

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prevents salivary and bloodsplatter, and protects the pa-tients mouth and airway.

Using personal protectiveequipment (PPE), such as surgi-cal masks (with at least 95 percent efficiency against particles 3 to 5 m in diameter; changedfor every patient or every 20 min-utes in an aerosol environmentor 60 minutes in a non-aerosolenvironment), safety glasseswith lateral protection to pre-vent contact with eyes, as well as disposable gowns and gloves toreduce the penetration of or con-tact with bacterial aerosols andsplatters, is vital (Tab. 2).

Regular maintenance of theair-conditioning system is rec-ommended too, as good ventila-tion has a diluting effect on theairborne microbial load, espe-cially at night when the clinic is closed.14 Air samples taken atdifferent times at a multi-chairdental clinic showed that bac -terial aerosols are more con -centrated during treatment andthat there is higher concentra-tion of circulating bacterialaerosols at the beginning of theday, which may be related to reduced ventilation.14 Residualbacterial aerosols can be re-moved through air filters or ultraviolet light.

As splatters can travel as far as the door or supply counter inthe middle of a multi-chair dentalclinic,14 all clean, unused instru-ments and equipment should bekept in closed cabinets or draw-ers to prevent contamination.

Other important measuresthat must be taken to preventcross-infection include adequatesterilisation of dental instru-ments, disinfection of work sur-faces before and after each den-tal procedure, disinfection of all

dental materials and work sentout to the laboratory, and regularmaintenance of the dental waterlines and equipment, which hasthe potential to harbour bacteria.All dental water lines should bepurged at the beginning of eachday for between 5 and 10 minutesand flushed thoroughly with water, as residual water may be-come contaminated overnight andbiofilm may develop along the inner side of the tube. Purgingwill result in a significant de -crease in bacterial counts.15, 16

The Canadian Dental Asso -ciation recommends runninghigh-speed handpieces for 2030 seconds after each treat-ment to purge all potentially contaminated air and water. Thisprocedure has been proven to reduce the bacterial load in thewater line significantly.17 Bloodcells, as well as bacterial and viral particles, can survive insidehandpieces even after disin -fection. They must therefore besterilised between patients.18, 17

The clinic floor should be dis-infected and cleaned with an an-timicrobial disinfectant solutionat least twice per day to eradicateany bacterial residue from splat-ter or aerosols.

It is a well-known fact thatprivate dental clinics sometimesemploy dental assistants whohave not received certified train-

ing. Improperly trained person-nel, however, may lead to poorinfection control practices. It isthe responsibility of every dentistto educate and train his or her assistants in the standard pro -cedures. Furthermore, DHCPimmunisation status should beup to date.

It remains a difficult task toeliminate the risk of exposure to dental aerosols. The best wayto reduce the risks, however, is to employ routine cross-infec-tion protocols recommended bythe health authorities, such asthe CDC, WHO and ministries ofhealth. To date, various infectioncontrol reports and procedureshave been published to informand educate dental health carepersonnel (DHCP) about the im-portance of practising adequateinfection control.

Editorial note: A complete list of refer-

ences is available from the publisher.

DT

Special: Practice Hygiene DENTAL TRIBUNE Asia Pacific Edition No. 6/20148

Dr Safura Baharinis Head of Clini-cal Services at theFaculty of Den -tistry of the Na-tional Universityof Malaysia nearKuala Lumpur in

Malaysia. She can be contacted atsafurabaharin@ukm.edu.my.

Contact Info

page 7DT

Using personal protective equipment such as surgical masks, safety glasses aswell as disposable gowns and gloves is vital.

(DTI/P

hoto Tyler O

lsen)

DENTAL TRIBUNE Asia Pacific Edition No. 6/2014 Special: Practice Hygiene 9

Dr Sharon Liberali

Australia

The administrative aspects of

dentistry continue to become

more demanding with increas-

ing amounts of time spent in

fulfilling mandatory accredita-

tion requirements. It can often

feel overwhelming, taking us

away from the clinical practice

of dentistry, and there is a risk

that, owing to high clinical de-

mand, short-cuts may be taken.

However, infection controlmust be considered to be a cen-tral part of quality dental care. A purported commitment tohigh standards and the pursuitof clinical excellence is mean-ingless when low priority isgiven to quality issues in thefield. Failure to address all in-fection control requirements increases the risk of diseasetransmission, ultimately com-promising patient safety.

The importance of infectioncontrol in clinical dental practicesimply cannot be understated.While the tasks associated withthe decontamination and steril -isation processes of reusable instruments are now routine,consideration must be given tothe less obvious components ofthe infection control process thatcan unwittingly compromise thehealth of our patients. Identifyingwhen patients may potentially beinfected with bacteria or viruses,how these bacteria or viruses maybe transmitted in the health caresetting, and when we need to

apply transmission-based pre-cautions are increasingly gainingsignificance.

The microbial threats facingus today pose significant healthrisks, and the situation is not likelyto improve. The WHOs first globalreport on antibiotic resistance1

was released on 30 April 2014. It has identified that highly resist-ant organisms are now common-place and that antibiotic resist-ance is a serious worldwide threatto public health. Dentistry is notimmune to this.

Multi-resistant bacteria areprimarily transmitted either by direct contact or indirectly viacontaminated surfaces. Currently,the most problematic health care-associated multi-resistant organ-isms include those highlighted

in the WHO report: methicillin- resistant Staphylococcus aureus(MRSA), Escherichia coli and car-bapenemase-producing Gram-negative bacteria (e.g. Klebsiellapneumoniae).

Almost everything in a den-tal clinical setting can serve as a reservoir and/or a vectorfor opportunistic pathogenicorganisms.

This includes, but is not lim-ited to, work surfaces, computerkeyboards, the hands of healthcare workers, and dental equip-ment and/or devices. Surfacesin particular play a significantrole in the acquisition, persist-ence and spread of infections.

Clinically important micro-organisms that can cause healthcare-acquired infections havebeen shown to persist in everyhealth care environment forconsid erable periods. This fa-cilitates the spread of the or -ganism throughout a health carefacility, including the dental

setting, especially when pa tientswith multi-resistant organismsare not identified, and compli-ance with hand hygiene andsurface cleaning or disinfectionis poor.

Viruses from the respiratorytract (e.g. the influenza virus) canpersist on surfaces for severaldays, while blood-borne viruses(e.g. hepatitis B virus and HIV)can persist for more than oneweek. Herpes viruses (e.g. herpessimplex virus Types I and II) com-monly encountered in the dentaloffice can persist on surfaces anywhere from a few hours to as long as seven days. Bacteriacan persist for much longer. Most Gram-positive bacteria (e.g. MRSA) can survive formonths on dry surfaces, andmany Gram-negative species(e.g. E. coli and K. pneumoniae)can also survive anywhere fromweeks to months and can there-by be a continuous source oftransmission if no regular pre-ventive surface disinfection isperformed.2

The WHOs report high-lighted that health care workerscan help tackle antibiotic re -

sistance by enhancing infectionprevention and control. Everymember of the dental team mustfollow the standard proceduresrequired to prevent the trans -mission of micro-organisms, in-cluding hand hygiene, personalbarrier protection, instrumentdisinfection and sterilisationprotocols, as well as surface de-contamination strategies. Worksurfaces in the dental operatorythat are in the contaminated zonemust be cleaned after every pa-tient by wiping the surface with a neutral detergent, while worksurfaces outside the contami-nated zone must be cleaned aftereach session or when they be-come visibly soiled. The dentalteam should be fully aware of therisk of dissemination of po ten -tially hazardous micro- organ -isms and ensure that ef ficientcross-infection control proce -dures are properly maintained.

Editorial note: A complete list of refer-

ences is available from the publisher.

DT

Dentistry is not immune to threatsposed by antibiotic resistance

Dental Tribune International

The Worlds Largest News and

Educational Network in Dentistrywww.dental-tribune.com

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Almost everything in a dental clinicalsetting can serve as a reservoir and/or a vector for opportunistic

pathogenic organisms.

Three-dimensional illustration of an MRSA bacterium. (DTI/Photo courtesy of Michael Taylor)

Dr Sharon Liberaliis Director of theSpecial Needs Unitof Adelaide DentalHospital, and amember of the Infection Control

Committee of the Australian DentalAsso ciation. She can be contacted atsharon.liberali@health.sa.gov.au.

Contact Info

Special: Practice Hygiene DENTAL TRIBUNE Asia Pacific Edition No. 6/201410

DT Asia Pacific

ST LEONARDS, Australia/

DUNEDIN, New Zealand: Ow-ing to their internal construction,air or water syringes commonlyused in dentistry are generallyprone to bacterial contamina-tion. Using disposable ratherthan non-disposable syringe tipshowever could potentially de-crease the risk of cross-infection

between dental procedures,even when the latter kind havebeen thoroughly sterilised sev-eral consecutive times, re-searchers from New Zealandhave reported in the latest issueof the Australian Dental Journal.

Of 68 used non-disposable sy-ringe tips tested for microbiolog-ical growth, almost 40 per centwere found to be harbouring dif-

ferent kinds of bacteria after hav-ing been sterilised with a Class Bautoclave. According to the re-searchers, the level of contami-nation did not decrease signifi-cantly regardless of the numberof additional sterilisation cyclesthe tips were run through. Flush-ing the instruments simultane-ously with air and water beforethe cleaning and sterilisationprocesses also resulted in no

difference to the level of con -tamination, they said.

While control tips of the dis-posable kind also showed con-tamination, the level was signifi-cantly lower. The researcherssuggested that one of the mainreasons for the build-up of bac -teria or contaminants in non- disposable tips could be corro-sion facilitated by continuous

exposure of the instruments tohumidity during treatment,which increases the roughnessof the surface, allowing poten-tially harmful micro-organismsto accumulate over time. Whilesuch micro-organisms might beharmless, they recommend theuse of disposable tips over non-disposable tips to reduce the riskof cross-infection.

For the study, new and usednon-disposable syringe tips fromthe urgent care unit at the Schoolof Dentistry of the University ofOtago in Dunedin were inves -tigated. DT

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DT Asia Pacific

KOBE, Japan: While compli-ance with infection control prac-tice in Japanese dental officeshas improved lately, most den-tists still seem to be hesitant to treat patients with HIV/AIDS. A survey conducted by research -ers from the Department ofHealth Science at the Universityof Hyogo among practitioners inthe Aichi Prefecture has foundthat only one in three would bewilling to see patients with thedisease.

It also found that respondentswith a level of infection controlpractices that exceeded standardprecautions, such as wearing a mask or gloves during treat-ment, were more likely to treatHIV/AIDS patients.

The researchers conductedthe survey involving 2,100 dentistsin 2011, of which the majoritywere male, older than 50 yearsand worked in general prac tice.The results, while lacking com-pared with other developed coun-tries, are a step-up from those re-ported in an earlier survey in 1996,which found that only 15 per centof dentists were willing to treat patients with the disease.

The total number of HIV/AIDScases in Japan exceeded 20,000 in 2012, with the number of new infections per year remain-ing steady, according to figures from the National Institute of Infectious Diseases in Tokyo. In a report published last year, how-ever, the institution reported thata significant number of new in-fections appear to go undetected,labelling the national surveil-lance system as insufficient. TheDepartment of Global Health Pol-icy at the University of Tokyo haspredicted HIV/AIDS prevalenceto quintuple by 2040, particularlyin high-risk groups, unless newmeasures are introduced to thecountrys public health interven-tion framework. DT

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Special: Practice Hygiene DENTAL TRIBUNE Asia Pacific Edition No. 6/201412

Jane Armitage

UK

The cleaning of water lines issomething I would not nor-mally write about but this is going to be a personal articlethat I would like to raise aware-ness to. Last year I received a telephone call from a chestconsultant who told me that he thought he knew why I washaving recurrent chest infec-tions, tiredness, and persistentcough. He had taken three sputum samples from me andhad grown Mycobacteriumavium and Mycobacterium intracellulare, otherwise knownas a Mycobacterium avium- intracelluare infection (MAI)or MAC (Mycobacterium aviumComplex).

These bacteria are found liv-ing in house dust and tap water.They may infect wild or domesticanimals as well as humans. I hadnever heard of it and was veryself-composed when he told me it was a type of lung infection

caused by bacteria from the samegenus as the one which causesTuberculosis (Tb), but was non-contagious. Within a matter ofdays I was seen by a Tb special-ist and commenced treatmentthe following day. I was told that MAC mimics Mycobacterium tuberculosis (MtB) and is usuallyfound in thin middle age womenwith low immunity. He stated thathe wished I had had full-blowninfectious Tb as this would havebeen cleared in six months. Unlike Tb, it would take a treat-ment plan of 1824 months (threetimes as long as conventional Tb)and relapses are common evenafter taking what was describedas chemotherapy antibiotics.

I was ok until I saw that wordthen I freaked. How can this havehappened? How had I caught it?Was I going to die? These were allquestions I was throwing at him.He explained that this form ofnon-contagious mycobacterialinfection can be caught fromshower heads, soil, cigarette pa-pers, any form of sprayed water

or simply by breathing the bug in.I was told I had been unlucky andhis guess was I had breathed it in and slowly it had reached mylung and started to attack. The

bug was already in the whiteblood cells which are responsi-ble for removing infections in thebody. Therefore, it was difficult to get rid of.

MAC is resistant to many an-tibiotics; there are limited drugsthat can be given but all comewith extreme side effects which Iwas warned about. One drug canaffect the optical nerve in the eye,the other, your liver. I rememberlooking at the medication andputting it back in the bag as themere thought was freaking meout. I have now been on treat-ment for a year and cant wait un-

til I can come off. I have since hadnegative results and my X-ray is clear but I will have to remainon the drug regime as if there are any stray MAC bugs they willmultiply and I will become veryill again.

The consultant was im-pressed with how I had toleratedthe treatment as many throw the towel in before completion.Several times that thought hadcrossed my mind, but I wantedrid; I wanted to be me again. Myreasons for sharing this infor -mation is to ask you all to beaware that this can come fromsprayed water, so please ensureyour water lines are cleaned with one of the many waterlinecleanser/disinfectants manu -factured. Biofilms form rapidlyon dental unit waterlines. Themajority of the organisms in thebiofilm are harmless environ-mental species, but some dentalunits may harbour opportunisticrespiratory pathogens.

Effective infection control isone of the cornerstones of goodpractice and clinical gover-nance. Due to a combination ofnegative publicity and an in-

creased scientific knowledge ofdental unit waterlines (DUWL)biofilms and their associatedrisks, contamination of dentalunit waterlines has become aprominent infection control is-sue. Flushing the waterlines fortwo minutes at the start of the dayand for 2030 seconds betweenpatients reduces the bacterialcount but in DUWL where thismethod is used as the sole meansof water quality managementflushing is unlikely to providewater of drinking water standardi.e. with a total bacterial count of 100 CFU/ml, nor will flushingremove the biofilm.

However, in dental units,which are not drained down atnight, flushing at the start of theday will help to reduce the bacte-rial load caused by overnight wa-ter stagnation. Flushing betweenpatients helps to prevent crosscontamination by removing anysuck-back of oral fluids that havebypassed the anti-retractionvalve. It is recommended to usebiocides to control the biofilm bydaily draining down and clean-ing of the waterlines to reducebiofilm build up. The biocide(disinfectant) can be introducedwith a pressurised pump or via an independent reservoir bottle.

I didnt catch my illness fromour water lines but since I havebeen ill the people around mehave looked not only at their water lines but at their cleaningmethods at home. Many have

changed their shower heads sooften that Im thinking of askingfor commission. The Health &Safety Executive and the De -partment of Health here in theUK have issued guidance for the treatment of DUWL. I urgeyou all, wherever you are, to ensure these means of testingand cleansing the water lines are carried out. A risk assess-ment for managing water linesshould also be carried out. I would also advise you to look at your home, clean the shower-heads, and run the shower for a couple of minutes before use.

I have been unfortunate. Dontlet this opportunistic patho geninto your life. DT

The importance of clean water lines

...some dental units mayharbour opportunisticrespiratory pathogens.

Jane Armitageis currently apractice man-ager for Thomp-son & ThomasFamily DentalCare in Sheffield

in the UK. She can be contactedat janearm@ tiscali.co.uk.

Contact Info

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(DTI/Photo Zhang Xiangyang)

DTAP0614_07-08_BaharinDTAP0614_09_LiberaliDTAP0614_10_SpecialDTAP0614_11_Adec_ADDTAP0614_12_Armitage