You are on page 1of 20



Steps in development of infection

Types of infection in dentistry

Modes of disease transmission

Routes of entry of microorganism into our body

Pathway of infection transmission in dental office

Agents of sterilisation

Universal precaution

Methods of infection control

Bioaerosols in dental office

Universal precautions

Standard precautions

Operation theater setup and protocols

Surgical scrub

Protective attire and barrier technique

Draping a patient and patient position

Gowing before surgery and handling of intrument

Cleaning of instrument and disinfection of dental labs and radiographic units

Types of mask and gloves

Gloving of hands



Dental environment is associated with significant risk of exposure to various
microorganisms. Many infectious(blood, saliva) bacteriemia or viremia associated
with systemic infections. Dental patients and dental surgeons exposed to variety of
microorganisms via blood ,oral or respiratory secretions. (cytomegalovirus, hepatitis
B virus, hepatitis C virus, herpes simplex virus type 1 and type 2, HIV,
mycobacterium tuberculosis, staphylococci, streptococci and other viruses and
bacteria- specially those that infect the upper respiratory tract.) Infections may be
transmitted in the dental operatory through direct Contact - With the blood, oral
fluids, other secretions.
Indirect Contact- Contaminated instruments, operatory equipment or environmental
surfaces or contact with air borne contaminants present in either droplet spatter or
aerosols or oral or respiratory fluids. Infection via these routes require that all of the
three conditions be present.

Steps in Development of Infection

Source of microorganisms

Spread of microorganism to a new person

Escape of microorganism from a source

Entry of microorganism into the person

Infection(survival and growth of microorganism)

Damage to the body

Types of Infection

Endogenous infection
Diseases that originate within the individuals body and are not transmitted
from another infected individual.
E.g- metabolic disorders


Exogenous infection
Diseases originating from outside an individuals body. These are caused by
pathogenic microorganisms that invade the body such as radiation, chemicals,


Nosocromial infection
Are acquired by a patient in hospital or long term care facility. Common
examples are staphylococcal infections and pseudomonas. Most common
causes are improper hygienic methods and break in the chain of sterility.


Oppurtunistic infection
They occur when the bodys ability to resist disease is weakened. These
opportunistic infections do not infect persons with intact immune system. Ex:
Kaposi sarcoma

Stages of Infection

Incubation stage:Interval between the exposure to pathogenic microorganism and the first appearance
of signs and symptoms of the disease.

Prodomal stage:Indicates the onset of disease and is characterized by symptom

Acute stage:Disease has reached the peak and signs and symptoms are fully developed and
differentiated from other specific symptoms.

Declining stage:Patient signs and symptoms has begin to decline.

Convelescent stage:Recovery and recuperation of the disease has started to occur and patient begins to
regain its health.

Bioaesosol in Dental Clinic

Bio aerosols are living microbes that travel via a mist and may contain bacteria,
viruses, molds, fungi or yeast. These air borne microorganisms can be found inside a
dental office, coverings, surfaces etc. because aerosols are generally invisible, most
individuals are unaware of their presence. Alginate powder mixed with water can
become a aerosol and can cause bronchial irritation if inhaled

Air turbine hand pieces, scalars, air water sprays, rotary instruments, dental lathes all
have the potential of producing aerosols contaminated with microorganisms.Normal
oral flora, bacterial plaque, calculus, respiratory disease, caries, herpetic lesions,
Tuberculosis and intraoral infections are potential intra oral sources of infections
caused due to inhalation of BIO AEROSOLS.

Agents Use in Sterilisation


Physical Agents


Drying:- Flaming, Incineration, Hot air oven

Moist heat :-

Pasteurisation, Boiling,Steam under pressure ,Steam under


Filtration:- Candles, Asbestose, Pads , Membrane


Ultrasonic and sonic


Chemical Agents:

Alcohol :- ethyl alcohol , isopropile alcohol, trichlorobutanol

Aldehydes :- formaldehyde, glutaraldehyde



Surface active agents

Metallic salt


Sunlight Possesses appreciable bactericidal activity

Action is primarily due to UV-rays

Mostly used in tropical countries


Spores are Moisture is essential for growth of bacteria.

4/5th wt. not affected by drying.


Most prominent anti microbial agent




Steam under pressure





Hot air

Dry Heat Kills by Oxidation Effect


FLAMING:- Scalpels,blades,needles,mouth of culture tubes,botteles,glass

slides and cover slips are sterlized by this method.


INCINERATION:-Effective method for rapidly destroying contaminated

materials such as soiled dressings and pathological material, etc.



holding period:-

At 160 for 2hrs

At 170 for 1hr

At 150 for 2&1/2hrs

Hot Air Oven:

Dry heat penetrates less and less effective than moist heat.

Higher temperatures and longer time is required.

So it is essential that hot air oven should have time lock on the door.

Materials sterlized- All glass syringes,test tubes,petri dishes and flasks,metal

instruments such as forceps,scissors,scalpels,sealed material such as
oils,greeses and dry powder.

Moist Heat: Steam Under Pressure
Autoclave: Chamber which is filled with hot steam under pressure. Preferred method of
sterilization, Temperature of steam reaches 121oC at twice atmospheric pressure.
Holding Time:-

At 15psi 121C for 15mins

At 15psi 126C for 10 mins

At 15 psi 134C for 3mins

Most effective when organisms contact steam directly or are contained in a small
volume of liquid. All organisms and endospores are killed within 15 minutes. Suitable

for sterilization of Culturemedia, Aqueous solutions, dressing material, linen, gloves,

Control Test:-Thermo couple, Browns test, bowie-dick test, steoro thermophilus
spores Require more time to reach center of solid or large volumes of liquid.

Sonic Ultrasonic

Universal Precautions
ADA recommends that blood and body fluid precautions be used consistently for all
Patients. This extension of blood and body fluid precautions referred as Universal
Precautions must be observed routinely in the care of all patients.

Standard Principles of Infection Control/ Universal Precautions

Hand hygiene and skin care.

Protective Clothing.

Safe Handling of Sharps (including Sharps Injury Management).

Spillage Management.

All blood and body fluids are potentially infectious and precautions are
necessary to prevent exposure to them.

A disposable apron and latex or vinyl gloves should always be worn when
dealing with excreta, blood and body fluids.

Everyone involved in providing care in dental practice should know and apply
the standard principles of hand decontamination, the use of protective
clothing, the safe disposal of sharps and body fluid spillages.

Each member of staff is accountable for his/her actions and must follow safe

OSHA (Occupational Safety and Health Administration) For Dentistry

Provide Hepatitis B immunization to employees without charge within 10 days
of employment.

Require that universal precautions be observed to prevent contact with blood

and other potentially infectious material. Saliva is considered to be blood
contaminated body fluid in relation to dental treatments.

Implementing engineering controls to reduce production of contaminated

spatters, mists and aerosols.

Implement work practice control precautions to minimize splashing, spatter or

contact of bare hands with contaminated surfaces. Provide facilities and
instructions for washing hands after removing gloves and for washing skin
immediately or as soon as feasible after contact with blood or potentially
infectious materials. Prescribe safe handling of needles and other sharp items.

Contaminated sharps are termed as regulated waste and must be discarded in

hard walled containers.

Contaminated equipment that has to be serviced must first be decontaminated

or a bio hazard label must be put on it.

Personnel handling sharps must not reach out with his hands inside the

Provide laundering of PPE(Personal Protective Equipment) to the employees

without any cost.

Provide vaccination for all employees under no cost against all infectious that
could be prevented by immunization. Some of the infections that require
immunization in the dental setting are HEPATITIS, RUBELLA, MEASLES.

Prescribe disposable or single use needles, sharps and dispose them as soon as
feasible in a hard walled leak proof containers that are closable. Containers must be
red or bear a biohazard label. Teeth must be discarded into sharp containers.

Contaminated reusable sharp instruments must not be stored or processed in a manner

that requires employees to reach hands into containers to retrieve them. Prohibit
eating, drinking, handling contact lenses etc in contaminated environments. Ban
storage of foods and drinks in refrigeration or other spaces where blood or infectious
materials are stored.
Place blood and contaminated specimen to be transported into a suitable closed
container that prevents leakage. Provide PPE to employees and clear directions for
use of universal precautions. Ensure the correct use of PPE. As soon as feasible the
working surface and environment must be sanitized after treatment. Provide a written
schedule for cleaning.

Surgical Scrub
Surgical hand washing destroys transient organisms and reduces resident flora before
surgical or invasive procedures.At the start of a session, an aqueous antiseptic
detergent solution is applied to moistened hands and forearms for approximately 2
minutes. The nails are scrubbed and a manicure stick can be used to remove dirt from
beneath the nail. The disinfection process must be thorough and systematic, covering
all aspects of the hands and forearms. The procedure should take 3 to 5 minutes.
Preparations currently available are 4% chlorhexidine and 7.5% povidone-iodine
solution. The hands must be thoroughly dried with a sterile towel prior to donning
sterile gloves.

The purpose of surgical hand scrub is to eliminate transient flora and reduce resident
flora for the duration of the procedure to prevent introduction of micro-organisms in
the operative wound.

Hands must be washed:

Before and after each work shift or work break. Remove jewellery (rings)

Before and after physical contact with each patient.

After handling contaminated items such as dressings.

Before putting on, and after removing, protective clothing including gloves

After using the toilet, blowing your nose or covering a sneeze

Whenever hands become visibly soiled

Before eating, drinking or handling food and before and after smoking.

An Effective Hand Washing Technique Involves Three Stages:


Before washing hands, all wrist and, ideally, hand jewellery should be
removed. Cuts and abrasions must be covered with waterproof dressings.
Fingernails should be kept short, clear and free from nail polish. Hands should
be wet under tepid running water before applying liquid soap or an
antimicrobial preparation.


Washing and Rinsing

Wet the hands under running water. Apply the hand wash solution ensuring
that it comes into contact with all of the surfaces of the hand. The hands must
be rubbed together vigorously for a minimum of 10-15 seconds, paying
particular attention to the tips of the fingers, the thumbs and the areas between
the fingers. Hands should be rinsed thoroughly. When decontaminating hands
use an alcohol hand rub, hands should be free from dirt and organic material.
The hand rub solution must come into contact with all surfaces of the hand.
The hands must be rubbed together vigorously, paying particular attention to

the tips of the fingers, the thumbs and the areas between the fingers, until the
solution has evaporated and the hands are dry.

This is an essential part of hand hygiene. Dry hands thoroughly using good
quality paper towels. In clinical settings, disposable paper towels are the
method of choice because communal towels are a source of crosscontamination. Store paper towels in a wall-mounted dispenser next to the
washbasin, and throw them away in a pedal operated domestic waste bin. Do
not use your hands to lift the lid or they will become re-contaminated.

Protective Attire and Barrier Techniques Gloves for Protection

For protection of personnel and patients medical gloves must be worn by the dentist
when there is potential for contacting blood, blood contaminated saliva, or mucous
membranes. Non sterile gloves are suitable for examinations and sterile gloves are
suitable for any surgical procedures. Before treatment of each patient, dentist should
wash their hands and put on a new gloves, and after treatment should discard the
gloves and wash their hands.
Surgical gloves should not be washed, disinfected, or sterilized for reuse as by doing
these procedures gloves may cause WICKING i.e. penetration of liquids through
undetected holes in the gloves. Use of chemical solutions, heat treatment, autoclaving
may cause deterioration of gloves.

Steps in Waring Gloves

When gloves are torn, cut or punctured, they should be removed as soon as patient
safety permits. Dentist then should wash their hands thoroughly and reglove to
complete the dental procedure. Dentist who have exudative lesions or weeping

dermatitis, particularly on the hands should refrain from all direct patient care and
handling dental patient care equipment until the condition resolves

Patient Care Glove:-

Sterile Latex Surgial Gloves

Sterile Neoprine Surgical Gloves

Sterile Styrene Gloves

Sterile Copolymer Gloves

Latex Examination Gloves

Vinyl Examination Gloves

Nitrile Examination Gloves

Polyurethane Gloves

Powderless Gloves

Flavored Gloves

Lowprotein Gloves

Utility Gloves:

Heavy Latex Gloves

Heavy Nitrile Gloves

Thin Copolymer Gloves

Thin Plastic Gloves

Masks, Face Shields, Eye Wear

Chin length plastic face shields, surgical masks and protective eye wear should be
worn when splashing or spattering of blood or other body fluids is likely to come in
contact. When a mask is used it should be changed between patients or during patient
treatment if it becomes moist or wet. Face shields and eye wear should be washed
with a cleaning agent regularly.

Protective Clothing
Protective clothing such as reusable or disposable gowns, lab coats or uniforms must
beworn when clothing is likely to be soiled with blood or body fluids. Reusable
protective attire can be washed according to the manufacturers instructions. Protective
clothing should be changed once daily or is visibly soiled. These attire should be
removed once the dentist leaves the dental Office.

Use and Care of Sharp Instruments

Sharp instruments like needles, scalpel blades, surgical instruments contaminated with
patient saliva and blood should be considered as potentially infected and handled with
care to prevent injuries. Used needles should never be recapped or otherwise
manipulated using both hands, or any other technique that involves directing the point
of a needle toward any part of the body. Either a one handed scoop technique or a
mechanical device holding the needle sheath should be employed. Used disposable
syringes, needles, scalpels, sharp instruments must be placed in appropriate puncture
resistant containers. Bending or breaking needles requires unnecessary manipulation
and thus is not recommended

Clinical sharps should be single-use only.

Do not re-sheath a used needle - if this is necessary a safe method - for

example, a resheathing device - must be used .

Discard sharps directly into a sharps container immediately after use and at the
point of use .

Carry sharps containers by the handle - do not hold them close to the body .

Never leave sharps lying around .

Do not try to retrieve items from a sharps container.

Lock the container when it reaches the fill-line, using the closure mechanism.

Place damaged sharps containers inside a larger sharps container.

Operation Theatre Protocols


Touching as few surfaces as possible

Minimising of dental Aerosols & splatter

High volume evacuation

Saliva ejectors

Use of the rubber dam

Pre-procedure mouth rinse

Use of disposables

Housekeeping & cleaning

Other aseptic techniques

Operation Theatre Set Up

Operating room should have 2 sets of doors.

Operation theater ceiling, walls & flooring should be disinfected regularly.

Operation theater access should be restricted to O T personnel only.

Operation theaters are disinfected by fumigation.

Operation theater personnel should do a special scrub & dressing before

entering to O T.

Principles in Design Of Operation Theater:A.

Outer Reception Area Includes:-

The reception office.

The reception waiting room for patients & relatives.

An area for trolleys storage .

An area of hanging gowns for relatives & parents.


A Clean Zone:Which is wide clean corridor giving access to anesthetic room ,recovery room,
clean storage area, emergency autoclave , x-ray machine

The Operating Theater

OT should have a double door entrance from anesthetic room & a double door
entrance to the clean corridor. There should be 2 small doors one towards store room
from sutures dressings etc are taken & one from scrub room into the OT. Temperature
should range from 19 C to 22 C with humidity of 45-55%. Adequate no. of power
plugs should be there.
Operating table should be regularly checked for smooth raising & lowering of table &
for tilting of table for trenderlenburg position & lateral tilt position. OT lights should
also be adjustable easily with removable handles so that it can be sterilized and
handled by OT personels. Tubings and devices should be covered with the disposable
sheets which can be removed easily after use. OTs should be spacious enough so that
troleys and staff can move around table easily.

Sterilisation in Operation Theaters

Fumigation of Operation Theater

The O T is disinfected by fumigation .

Fumigation can be achieved by fumigators as well as potassium

permanganate reaction technique.

Fumigation is done with the instrument STERITRAX

Fumigation chemical used is 40% FORMALIN.

Fumigator is set for 30 mins with timer adjustments in the instruments

The Scrub Room:

It should have 2 doors one from corridor & one to OT.

Sinks with taps & soap holders that can be manipulated with elbows
should be present.

Sink design should be such that splashing on clothes is prevented.

Antislip floors easily cleaned shelves for gown packs & gloves should
be present.

Brushes for cleaning fingernails should be available.

Contents of Scrub Suite:

A pair of pants/skirts/pyjamas & shirts;

A pair of masks , a head cap & a pair of gloves

A pair of O T shoes (conductive shoes are preffered to avoid any explosion

due to static charges which may induce fire in inflammable anesthetics

A surgical gown which are tied at its back by some non scrubbed staff so it
is non sterile at its back & below the waist . so one should keep his hands
above waist when not operating.

Draping the Patient/ Preparation of Surgical Site:Hair in the area of surgery are shaved off just before the scrubbing of the skin. The
time interval between the shave and skin preparation should be decreased. A
lubricating ointment is applied to eyes & they are covered with sterile towel. The
external auditory meatus is plugged and blocked if bleeding is anticipated. The
scrubbing should begin at the centre of surgical site

& moved outwards

concentrically away from the site of operation to avoid the contamination of already
scrubbed site.
During intra oral procedures the mouth is rinsed with chlorhexidine mouth wash to
reduce the bacterial count in oral cavity. The iodophor compounds are effective for
skin preparation. Patient`s hair are covered with sterile head cover . Another towel
should cover chest and shoulders. Patient should be draped with sterile towels to
isolate the area of surgery & the suction tube is clipped to this towel so as to prevent it
from falling down. The site of needle puncture is made dry & 0.5 % chlorhexidine is
applied at that site. While operating the operating person can touch only the sterilized
drappings & sterile instruments handed over by assisting staff.

Dental environment is associoated with significant risk of bacterias, virus. So it is
very important maintain asepsis.To create a healthy environment instruments, hand
hygiene,protective clothing sterilization is important special care should be required
to maintain aseptic environment it includes proper disposal of blood,saliva containing
objects sharp instruments should be properly handled asepsis should be maintained by
the dentist for the prevention of patient and dentist itself.


Textbook of Microbiology for dental students(3rd edition) by D.R.Arora and

Brij Bala Arora.

Textbook of Microbiology - 7th edition (ananthnarayan and paniker).

Dr.Neelima Anil Malik: Textbook of Oral & Maxillofacial Surgery, 1st


Satish Chandra, Shaleen Chandra, Girish Chandra : text book of Operative

Dentistry, 1st Edition.

Ramya Raghu, Raghu Srinivasan : Clinical Operative Dentistry- Principles &

Practice, 1st Edition.

Monheims Local anesthesia and pain control in dental practice by C.Richard

Bennet(seventh edition).