Transcript Infectious Conditions among unprotected and non

Dental Innovative Devices &Educational Solutions LLC
Introduction
to
Dental Infection Control
by
Dr. Raghunath Puttaiah
Principal Partner
Dental Innovative Devices & Educational Solutions
Plano, Texas, USA
Introduction & Rationale
• Infectious diseases have
changed the course of history
“Between smallpox and Spaniards,
3/4ths of the Inca were wiped out
within 70 years.” [National Geographic]
Pizzaro1
1. "Francisco Pizarro." Wikipedia, The Free Encyclopedia. 9 Sep 2006,
22:12 UTC. Wikimedia Foundation, Inc.
"Siege of Tenochtitlan." Wikipedia, The Free Encyclopedia.
8 Sep 2006, 15:56 UTC. Wikimedia Foundation, Inc.
Pioneers in Infection Control
Wikipedia
Wikimedia
Wikimedia
Ignaz Semmelweiss
•Childbed fever caused by
Physicians & Medical Students
•Washing hands reduced rates
from 18% to <2%
•Findings not accepted by peers
Joseph Lister
•Using Carbolic Acid reduced
nosocomial infections in the
Glasgow General Hospital
•Findings well accepted
Sushrutha
•Considered the father of surgery
•400-800BC
•Wrote a Treatise on Surgery
•Used Fumigation Techniques
•Cleaned surgical site with
medicinal extracts, flamed instruments
Basic Concepts in Infection Control
Dental Clinic
Bacterial aerosols and fomites
P A T I E NT
Family
&
Friends
Dentist & Clinic Staff
Other Patients
Possible spread of a disease cluster
Family
&
Friends
Basic Concepts in Infection Control
Dental Clinic
Bacterial aerosols and fomites
#3
P A T I E NT
#6
Family
&
Friends
#5
# 4
#3
Dentist & Clinic Staff
# 2
Other Patients
Possible areas of control to reduce risk of disease
#1
Family
&
Friends
Routes of Transmission
1.
Percutaneous
high
Microbes in Blood/Saliva
–
2.
needle, sharp instruments
Contact
high
Microbes in Blood/Saliva
–
3.
splash/spatter of blood & body
fluids
Inhalation moderate
1
2
Suspended Microbes
–
4.
droplet nuclei and aerosols
Indirect contact low
Microbes on Surfaces
–
Fomites/touching contaminated 3
surfaces
4
Infectious Conditions among unprotected and non-immunized
DHCWs, & Restriction of Clinical Duties
Condition
Conjuctivitis
Staph. Active
Strep. A
Viral respiratory
TB (active)
TB (+ve PPD)
Restr.
Yes
Yes
Yes
Yes
Yes
No
Influenza
Yes
Headlouse.org
Duration
Until discharge ceases
Until lesions have healed
Until 24 hours after starting TX
Until acute symptoms resolve
Until treated non-infectious
Evaluate for infectious status
and care as needed)
Until DHCW is asymptomatic
Infectious Conditions among unprotected and non-immunized
DHCWs, & Restriction of Clinical Duties
Condition
Pediculosis (Lice)
Herpetic whitlow
Herpes - Orofacial
Restr.
Yes
Yes
Yes
Varicella (Ch. Pox)
Shingles (Zoster)
Hep-B (HBe antigen)
Yes
Yes
Yes
Hepatitis C
No
HIV
Yes
Duration
Until treated and is with no lice
Until lesions heal
Until clinical lesions are healed
(need to be on regular anti-viral meds)
Until lesions dry and crust
Until lesions dry and crust
Until Hepatitis-B e antigen is negative
(UP, expert panel and care)
UP/SP, Aseptic techniques and care
to reduce viral load
Expert panel, UP/SP, antiviral meds
Infectious Conditions among unprotected and nonimmunized DHCWs, & Restriction of Clinical Duties
Condition
Measles
Mumps
Rubella
Pertussis
Restr.
Yes
Yes
Yes
Yes
Duration
Until 7 days after rash appears
Until 9 days after start of parotitis
Until 5 days after rash appears
Until 5 days after start of effective
antibiotic therapy
Diarrhea
Enteroviral
Hepatitis A
Yes
Yes
Yes
Until symptoms resolve
Until symptoms resolve
Until 7 days from onset of Jaundice
Standard Precautions/
Universal Precautions
Definition:
– to treat all patients as potentially infectious and not to
base the level of infection control on the appearance or
disease status of patient
What defines the level of control?
– Level of control to be based on type of procedure and
reasonably anticipated type of exposure
Adaptation of Spaulding’s
Classification to clinical surfaces
1.
2.
3.
4.
Critical
Semi-critical surfaces
Non-critical surfaces
Environmental surfaces
Critical items
Sharps that pierce the skin or mucosa
Semi-critical
Items that enter the mouth but are not sharp
Non-critical
spray
wipe
Items that do not enter the mouth but those that
are touched often during care
spray
Spaulding’s Classification of Surfaces
1.
1
2.
2
3.
3
4.
4
Critical:
STERILIZATION
•
Items that pierce skin or mucosa
–
Explorers, scalpels, scalers, burs & other sharps
Semi-Critical:
STERILIZATION
•
Non-sharp items that enter the oral cavity
–
Amalgam condensers, mirrors, handpiece
Non-Critical:
DISINFECTION
•
Items not entering the oral cavity
–
Bracket table, face-bow, chair controls
Environmental:
HOUSEKEEPING
•
Walls, floors and environmental surfaces
Environmental surfaces
Dusting
Sweeping
Swabbing
Walls, floors, wall hangings that can be
managed by housekeeping
Other common infection control
& safety issues
Do’s and Don'ts
Do’s and Don'ts
Do’s and Don'ts
Length Of Nails
Acceptable
Length Of Nails
Questionable
No Open Wounds, including
Paper-cuts
Use a dressing and
then wear gloves
Common Infectious
Diseases in Dentistry
• Sexually Transmitted Diseases:
• Herpes Simplex
– Whitlow, gingivostomatitis, eye
infection
1
2
•
•
•
•
Goncoccal Infections
Chlamydial Infections
Trichomonal Infections
Syphilis
– oral lesions
• Infectious Mononucleosis
• Hepatitis B, C, D Virus Infections
• Human Immunodeficiency Virus
Infection
3
4
• Respiratory
Diseases:
aerosols
droplet

– Common Cold
– Sinusitis
– Pharyngitis
– Pneumonia
– Diphtheria
– Tuberculosis
Pediatric
• Childhood Diseases:
– Chickenpox (Varicella)
– Herpangina
– Hand, foot and mouth disease
– Rubella
– Rubeola
– Mumps
– Cytomegalovirus infection
lesion
blood
saliva
mucosa
droplet
aerosol
ingestion

Common childrens’ diseases
Mumps
Chicken Pox
• Hepatitis A & E
(fecal-oral)
• Commonly in lesser
developed regions
• A = picornoviridae, RNA
virus
– jaundice and rarely death
– incubation 4-6 weeks
– on recovery, life-long
immunity
• E = similar to HAV
– higher rate among
pregnant women
Hepatitis
• Hepatitis B Infection
– DNA Hepadnavirus
– Most not clinically identified
– USA is Low to moderate in Prevalence
– Incubation 45 - 160 days (chronic)
– Percutaneous and Non-Percutaneous
Infection from Patient <=> Dentist
• Outcomes of HBV infection
– about 90% show resolution
– 9 - 10% become asymptomatic Carriers
• suffer from chronic hepatitis
• develop hepatocellular carcinoma
– about 1% fulminant death
– Rate of infection among dentists
• 13.6 % to 38.5 %
– All DHCW should be immunized
• Hepatitis C Infection
– Parenterally transmitted
Non-A Non-B
– Associated with
• Blood and Body Fluid
– 60 % develop chronic liver
disease
• of the above, 30-60 %
show active liver disease
• 5 - 20 % develop cirrhosis
of liver
Hepatitis-B Virus-Carrier Serology
•
•
•
•
•
Carriers show lower number of symptoms
Have a subclinical scenario
Are normally HBeAg Positive & Contagious
HBsAg & HBeAg in blood precedes jaundice
In dentistry it is difficult to clinically identify a
patient who is a carrier, therefore Strict IC
• Practice Restrictions for HBeAg Positive DHCW
Hepatitis B Virus Pretesting & Post-testing
• Pretesting (anti-HBs) :• Some are doing the pretesting???
• Post-testing (anti-HBs) :• Testing within 6 months after vaccination
• Negative = primary non-responder or responder with
low detectable levels but still protected
• Booster Doses and Antibody persistence :• Till now, no booster doses in the US
Hepatitis D & Hepatitis G
• Hepatitis D Infection
– Bloodborne virus-like particles
– always dependent on HBV infection
– either a co-infection or super-infection
• Piggy-back Virus
– Mode of transmission similar to HBV
– Not uncommon during pregnancy
• Hepatitis G Infection
– Newly identified bloodborne condition
Spread of HIV & AIDS
1
2
SE
NY
NY
SF
SF
CH
CH
DEN
LA
LA
A
D
HI
HI
HO
HO
PR
PR
3
4
HI
HI
PR
M
PR
High Risk Groups
•
•
•
•
•
•
•
•
Multiple sex partners :
Heterosexual, homosexual or bisexual
Intravenous Drug users
Hemophiliac treatment
Blood Transfusion before Spring 1985
Steady sexual partners to the above 4 groups
Infants born to people of the above 5 groups
Very few risk groups spared
Outcomes of Exposure
Exposure
No Infection
Acute Disease
Infection
Asymptomatic PGL
AIDS
HIV Seropositive only
No AIDS
HIV & AIDS-Oral Manifestations
•
•
•
•
•
•
•
•
•
Oral hairy Leukoplakia
Candidiasis
Intraoral KS
Associated cervical lymphadenopathy
Recurrent herpes simplex virus
Papillomas
HIV associated gingivitis (HIV-G)
HIV associated periodontitis (HIV-P)
HIV associated necrotizing gingivitis
Risk of Occupational Transmission of HIV
• More than 1400 HCWs (with exposure) tested
• Of the 1000 with significant exposure, only 4 converted
to HIV-seropositive state in 6 months
• 100 HCWs with sharp injuries, no conversion
• 691 with mucosal contact to Blood and Other Potentially
Infection Materials (BOPIM), no conversion
• 235 HCWs with 644 sharp injuries, 1 seroconversion
SEROCONVERSION RATE IS < 1.0%
Tuberculosis
• One of the oldest known
diseases
• Was under control for some
time
• Back with Vigor as MDR-TB
• 8 million people affected
every year
• 3 million die every year
• Insidious symptoms
• Periodic testing for dentist
and staff
1Robert
Robert Louis Stevenson
Louis Stevenson's sarcophagus, on top of Mount Vaea,
Upolu, Western Samoa. Photo credit-- David Morens.
Tuberculosis-Agents & Diseases
Common Organisms Diseases
M. tuberculosis
Pulmonary TB
M. bovis
Pulmonary TB
M. kansasii
Pulmonary TB
M. fortuitum
Cutaneous
M. intracellulare
Compromised
M. avium
Rare
M. chelonae
Rare
M. leprae
leprosy
M. gastri
None
M. smegmatis
None
Tuberculosis
Signs & Symptoms of Pulmonary TB
• Signs and symptoms :
•
•
•
•
•
•
•
•
night sweats
malaise
weight loss
fever
fatigue
chest pain
coughing sputum (possibly blood tinged)
cough and above symptoms for more than 3 weeks
Tuberculosis
Recommendation for Control
• Early Identification & Treatment :
– Screening questions and test high risk groups
– Refer positive cases for Medications and Followup
– Defer elective care and refer patient for TB-tests
– Refer urgent and emergency patients to facilities
equipped to provide care
Tuberculosis
Recommendation for Control
• Surveillance :
– Routine TB skin test for all HCWs
– Post exposure follow-up and care of HCW and
close contacts in the event of exposure
Tuberculosis
Implications for Dentistry
•
•
•
•
•
BUT :
High Aerosol procedures present in dentistry
Patients see dentists over many office visits
Therefore, may show a higher risk than expected
Use PPE, Barriers, HVE, TB-cidal disinfectant, Annual
Testing regularly
• Defer Elective and Refer for TB care