Infection Control

By Lydia, Salintorn (Fon), My Nu (Jenny), and Marzena

Instrument classificationInstrument Processing

DecontaminationMiele

Instrument Classification

● Critical instrument

● Semi-critical instrument

● Non-critical instrument

Critical Instruments [1, 2]

● Penetrate soft tissue, contact bone, or enter into or contact the bloodstream or other normally sterile tissue

● Method of decontamination○ Sterilization in steam under pressure: autoclave

○ Dry heat

○ Heat or chemical vapor

● Very high to high risk of disease transmission● Example

○ Extraction forceps and elevators

○ Scalpels

○ Bone chisels

○ Scalers

○ Surgical burs

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Semi-critical Instruments [1,2]

● Do not penetrate soft tissues or bone, but contact mucous membranes or non-intact skin

● Method of decontamination○ Sterilization○ High-level disinfection

● Moderate risk of disease transmission● Examples

○ Dental mirrors○ Reusable impression trays○ Amalgam condensers○ Mouth gag○ Dental handpieces

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Non-critical Instruments [1,2]

● Contact only with intact skin● Method of decontamination

○ Intermediate-level disinfection○ Low-level disinfection

● None to low risk of disease transmission● Examples

○ External components of x-ray heads○ Blood pressure cuffs○ Stethoscope ○ Light handles○ Chair-side computer ○ Dental chair

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Decontamination Methods Used for Dental Burs: A Comparative Study [3]

Method:● 96 contaminated round diamond burs (critical instruments)● Autoclave, glass bead, hot air oven, ultrasonic, manual scrubbing and for 3 glass

bead was found to be effective

Aims:● Assess the efficacy of different methods of detamination.

Results:● Autoclave: maximum reduction of Streptococcus mutans and Lactobacilli. [3]

Instrument Processing

● Devide area for instrument processing○ receiving, cleaning, and

decontamination ○ preparation & packaging○ Sterilization ○ Storage [4]

● Remove debris prior to sterilizing. [5]

● Wear heavy duty gloves. [5]

● Use mechanical cleaner, such as a Miele for decontamination. [5]

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Chemical Disinfectants on Contaminated Diagnostic Instruments [Ganavadiya]

�Materials:

● 30 participants ages 25-30 years old● Four different examinations using four different mouth

mirrors○ ocally manufactured mouth mirror○ standard plain mirror○ rhodium coated mirror○ disposable mouth mirror

�Procedure:● Use diagnostic instrument ● Stirred in normal saline to get a sample of the plaque

microorganisms.● Disinfect instruments for 30 minutes with assigned

disinfectant○ distilled water○ 2% glutaraldehyde solution○ 6% H

2O

2 ○ 99.9% ethyl alcohol.

● Nutrient agar as culture medium

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Results and Conclusion[6]

Results:

● All showed a decrease in microorganisms. ● Most significant microorganism reduction

○ Glutaraldehyde○ Ethyl alcohol

�Conclusion:

● Must be prevented cross contamination in clinical environment.

● An autoclave must be used to sterilize the instruments ○ All disinfector do not removed 100% of the

microorganisms

Decontamination

Importance of pre-cleaning

● Allow the steam to penetrate all surfaces of the instruments

Safety

● Wear full PPE

Methods of pre-cleaning

1. Manual Cleaning

2. Ultrasonic cleaning

3. Washer Disinfector: Miele

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Manual Cleaning [7]

● Simplest method to set up● Not a preferred method● Risk for splatter

○ Brushes became heavily contaminated with bacteria during use

● Risk for injury○ Wear heavy duty gloves○ Long-handled soft bristle brush

■ DO NOT use wire brush: surface abrasion

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Ultrasonic Cleaning [7]

● High intensity, high frequency sound wave● Less preferred than washer-disinfector● Advantage

○ Less risk than manual cleaning● Disadvantage

○ Accumulation of contaminants in the cleaning solution

○ Study: detectable blood in the cleaning solution increased with each instrument process

● Importance○ Fully open joint hinge, fully immerse

instrument, do not overload○ Manual rinse after

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Washer-disinfector: Miele [7]

● The most preferred method● Reduce risk of injury● Manual rinsing is not required (≠ultrasonic

cleaning)● Disadvantage

○ Long cycle time compared with other methods

● Importance○ Fully open joint hinge, fully immerse

instrument, do not overload● Study: washer-disinfector is the most

effective cleaning method

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Pre-cleaning method efficacy comparison [8]

Why Miele in Dentistry?

● Bioburden removal [7,9]

● Enhances handling safety [7,9]

● Most effectiveness cleaning

method [7,9]

Washer-Disinfectors vs Dishwasher [10]

Materials:

● 2 washer-disinfectors● 3 dishwashers

Methods:

● soil test● visual test● protein test● the total number of micro-organism (TVC) per

ml) in the rinse water

Result:

● Dishwasher did not pass the protein and TVC test

● Washer-disinfector passed all the tests

Conclusion:

● Washer-disinfectors ⇒ Effective● Dishwasher: Temperature not hot enough for

disinfection purposes

Procedure of Instrument Decontamination and Correct Operate Disinfector Miele

● P.P.E required: gown, mask, protective eyewear, utility gloves

1. Remove indicator strip

2. Remove debris on instruments with gauze

3. Place instruments parallel in the cassette without the tips of

instruments poking out of cassette

4. Turn on and open Miele using paper towel barrier

5. Check detergent level before operated: Darken 6. Place cassette in upright position (back to front)

- Using paper towel as barrier from step 7 to 12

7. Close Miele

8. Turn sign “Dirty” to “Clean” 9. Select “Disinfection Vario” setting at 93 degree Celsius

10. Press Start button

11. Beeping sound and flashing light indicates cycle ended

12. Open door partially for 5 minutes to release hot air and steam

13. Remove cooled instruments

14. Place indicator strip inside the cassette and place in enviropouch

15. Seal enviropouch with indicator tape and label date and autoclave number

Ethical Issues [10]

Non-maleficence

● an obligation to not harm and protect patients from harm

Beneficence

● to promote patient’s welfare

Amend section 1005 (a)(1) ● Apply Standard Precautions to all

patients.

Amend Section 1005 (c)(5) For disinfection, sterilization, and housekeeping procedures where contaminated items are handled,● Personal Protective Equipment (PPE) is

required. ● Gown, mask, protective eyewear, utility

gloves.

Amend Section 1005 (c)(9)(10)(12)● (9)(11) semi-critical and critical items

○ pre-cleaned packaged or wrapped and sterilized after each use.

● (12) non-critical and patient care items○ cleaned and disinfected with

EPA-registered hospital disinfectant

Legal Regulations [11]

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References1. ADA: Sterilization and disinfection of dental instruments [Internet]. Chicago: American Dental Association. Sterilization and Disinfection of Dental Instruments; 2009 Jul [cited 2016 Nov 20]; [3 p.]. Available from: http://www.ada.org/~/media/ADA/Member%20Center/FIles/cdc_sterilization.ashx2. Darby ML, Walsh MM. Dental hygiene theory and practice. Bowen DM, editor. 4th ed. St. Louis (MO): Elsevier; 2015. p. 113.3. Sajjanshetty S, Hugar D, Hugar S, Ranjan S, Kadani M. Decontamination methods used for dental burs - a comparative study. J Clin Diagn Res. 2014 Jun [cited 2016 Nov 25];8(6):ZC39-41. In: MEDLINE [Internet]. Ipswich (MA): EBSCO. Available from: http://library.foothill.edu:2195/eds/detail/detail?vid=3&sid=8fab92ab-fe0a-425e-8710-ccf093922fb8%40sessionmgr4010&hid=4108&bdata=JnNpdGU9ZWRzLWxpdmU%3d#AN=25121062&db=cmedm4. Infection Control [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2013 [cited 2016Nov28]. Available from: http://www.cdc.gov/oralhealth/infectioncontrol/faq/sterilization_cleaning.htm 5. Sterilization and Disinfection of Dental Instruments [Internet]. [cited 2016Nov26]. Available from: http://www.ada.org/~/media/ADA/Member Center/FIles/cdc_sterilization.ashx6. Ganavadiya R, Gupta R, Khandelwal G, Saxena V, Tomar P, Shekar BC. Disinfecting efficacy of three chemical disinfectants on contaminated diagnostic instruments: A randomized trial. J Basic Clin Pharm [Internet]. 2014Sep [cited 2016Nov27];5(4):98. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194945/ 7. Lamb B. Cleaning instruments prior to sterilization. Dent Nurs. 2011 September 2[cited 2016 Oct 24]:26-33. In: DOSS with Full Text [Internet]. Ipswich (MA). Available from http://library.foothill.edu:2208/ehost/detail/detail?vid=31&sid=efda5980-827c-4d4d-9c8d-811cb014d3a0%40sessionmgr107&hid=123&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#AN=67519519&db=ddh8. Vassey M, Budge C, Raven N. A quantitative assessment of residual protein levels on dental instruments reprocessed by manual, ultrasonic and automated cleaning methods. Br Dent J. 2011 May 14 [cited 2016 Oct 25];210(9):E14. In: DOSS with Full Text [Internet]. Ipswich (MA). Available from http://library.foothill.edu:2208/ehost/pdfviewer/pdfviewer?sid=efda5980-827c-4d4d-9c8d-811cb014d3a0%40sessionmgr107&vid=29&hid=1239. Class II special controls guidance document: medical washers and medical washer-disinfectors; guidance for the medical device industry and FDA review staff [Internet]. FDA US Food and Drug Administration; 2012 Feb 7. Description of the Medical Washer-Disinfector; 2015 July 1 [cited 2016 Nov 20]. Available from: http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm073357.htm10. O'Connor H, Armstrong N. An evaluation of washerdisinfectors (WD) and dishwashers (DW) effectiveness in terms of processing dental instruments. J Ir Dent Ass. 2014 April- May [cited 2016 Nov 26] 60(2):84-89. In: DOSS with Full Text [Internet]. Ipswich (MA). Available from http://library.foothill.edu:2206/eds/detail/detail?sid=8ba64022-64df-421e-a19d-7490651ece10%40sessionmgr102&vid=0&hid=117&bdata=JnNpdGU9ZWRzLWxpdmU%3d#AN=24812759&db=cmedm 11. Mathur S, Chopra R. Ethical issues in modern day dental practice. Online J Health Ethics [Internet]. 2012 Dec [cited 2016 Nov 20];8(2). Available from: http://aquila.usm.edu/ojhe/vol8/iss2/3/ DOI: 10.18785/ojhe.0802.0312. Dental Board of California Department of Consumer Affairs. 1105. Minimum standards for infection control [Internet]. Department of Consumer Affair [Cited 2015 Nov 27]. Available from: http://www.dbc.ca.gov/formspubs/1005isor/pdf