Infection prevention and control - Risk is the chance or probability that a person will be harmed or

experience an adverse health effect if exposed to a hazard.

- Infection prevention and control (IPC) is a scientific approach and
- It may also apply to situations with property or equipment loss, or
practical solution designed to prevent harm caused by infection to
harmful effects on the environment.
patients and health workers.
Adverse Health Effect
Objectives
- Any change in body function or the structures of cells that can lead to
- The protocols and procedures involved in the prevention and control of
disease or health problems
infection in dentistry are directed to reduce the possibility or risk of
cross-infection occurring in the dental clinic, thereby producing a safe Adverse Health Effect includes:
environment for both patients and staff.
 bodily injury,
Cross-infection  disease,
- The transmission of infectious agents from person to person or from  change in the way the body functions, grows, or develops,
inanimate objects within the clinical environment which results in  effects on a developing fetus (teratogenic effects, fetotoxic effects),
infection Adverse Health Effect includes:
Factors Influencing Infection Control Guidelines in Dentistry  inheritable genetic effects
 decrease in life span,
 change in mental condition
 effects on the ability to accommodate additional stress.
What makes risks significant?

 Potential for actual injury to patients or staff

 Significant occupational health and safety hazard
 The possibility of erosion of reputation or public confidence
 Potential for litigation
 Minor incidents which occur in clusters and may represent trends

Risk Assessment Hazard

- Risk assessment is the scientific evaluation of known or potential adverse
health effects resulting from human exposure to hazards.
Risk
- Risks can be clinical, environmental, financial, economic or political, as
well as those affecting public perception and reputation of the dentist or
the team.
- A situation, or substance, including micro- organisms, with the potential
to cause harm.
- A hazard is any source of potential damage, harm or adverse health
effects on something or someone.
- It is the role of managers of dental practices to manage risk.
- Infection control is an application of risk management to the dental
clinical setting.
Risk Management 3. Respiratory hygiene/cough etiquette.
4. Sharps safety (engineering and work practice controls).
- Risk management involves identification, assessment and analysis of
5. Safe injection practices (i.e., aseptic technique for parenteral
risks and the implementation of risk control procedures designed to
medications).
eliminate or reduce the risk.
6. Sterile instruments and devices.
- Risk control in dentistry is dependent on a single-tier approach, in which
7. Clean and disinfected environmental surfaces
all patients are treated without discrimination as though they were
 Safe waste management
potentially infectious.
- The practical interpretation of this concept, known as Standard Infection Transmission-Based Precautions
Control Precautions (SICPs), treats all body fluids, with the exception of
sweat, as a source of infection. - are the second tier of basic infection control and are to be used in
- SICPs are a series of measures and procedures designed to prevent addition to Standard Precautions for patients who may be infected or
exposure of staff or patients to infected body fluids and secretions. colonized with certain infectious agents for which additional precautions
- The ADA urges all practicing dentists, dental auxiliaries and dental are needed to prevent infection transmission.
laboratories to employ appropriate infection control procedures as
described in the 2003 CDC Guidelines, and 2016 CDC Summary and to
keep up to date as scientific information leads to improvements in
infection control, risk assessment, and disease management in oral health
care.

2016 CDC Summary:

Includes:
Fundamental elements needed to prevent transmission of infectious agents
in Dental Settings
Benefits of Risk Assessment
 Administrative measures
 Infection prevention Education and Training  Strives for optimal balance of risk
 Dental Health Care Personnel (DHCP) Safety  Supports better decision making
 Program Evaluation  Enables dentists to plan for uncertainty
 Standard Precautions  Helps the dentist comply with published standards and guidelines
 Dental Unit Water Quality  Highlights weakness and vulnerability in procedures, practices and
policy changes.
Risk assessment in dentistry involves the ff. steps:
Standard Infection Control Precautions
1. Identify the hazards.
1. Hand hygiene. 2. Decide who might be harmed, and how.
2. Use of personal protective equipment (e.g., gloves, masks, eyewear). 3. Evaluate the level of risk.
4. Record your findings.  Activities or work areas examined
5. Review your assessment periodically and revise it if necessary.  Hazards identified
1: Identify the hazards  Persons exposed to the hazards
 Evaluation of risks and their prioritization
 biological - bacteria, viruses, insects, plants, birds, animals, and humans,  Existing control measures and their effectiveness
etc.,  What additional precautions are needed and who is to take action and
 chemical - depends on the physical, chemical and toxic properties of the when
chemical
 ergonomic - repetitive movements, improper set up of workstation, etc., 5: Review assessment
 physical - radiation, magnetic fields, pressure extremes (high pressure or Risk assessment is a continuing process and must be kept up to date to ensure
vacuum), noise, etc., that it takes into account new activities and hazards, changes in processes,
 psychosocial - stress, violence, etc., methods of work and new employees.
 safety - slipping/tripping hazards, inappropriate machine guarding,
Hierarchy of Control Options
equipment malfunctions or breakdowns.
2: Who might be harmed?  elimination (buy in services/goods)
 substitution (use something less hazardous/risky)
- Identify all members of staff at risk from the significant hazard,  enclosure (enclose to eliminate/control risks)
including those who only come into contact with the hazard infrequently.  guarding/segregation (people/machines)
- Highlight persons particularly at risk who may be more vulnerable.  safe systems of work (reduce system to an acceptable level)
3: Evaluate Levels of risk  written procedures that are known and understood by those affected
 adequate supervision
 identification of training needs and implementation
 information/instruction (signs, handouts, policies)
 personal protective equipment (PPE).
Infection Control and the Law
Administrative Order No, 2016-002 (Jan 18, 2016)
National Policy on Infection Prevention and Control in Health Care
4: Facilities
Record your
findings - Enabling all healthcare facilities to implement IPC in mandatory
considering the development and spread of antimicrobial resistant
organisms and the emergence of new infectious agents.
General Guideline:
 Infection Prevention and Control is a vital component of quality health
care and patient safety, thus, all healthcare facilities in the Phil. shall
implement IPC program effectively.
Republic Act No. 4226
Hospital Licensure Act
Requires the licensure of all hospitals in the country and mandates the DOH
to provide guidelines for hospital technical standards as to personnel,
equipment, and physical facilities. The planning and design consider the
following criteria:
 Location and environment
 Occupancy
 Security
 Patient movements
 Lighting and ventilation
 Water supply
 Waste disposal
Presidential Decree No. 856
The Code on Sanitation of the Philippines
- Mandates the DOH to promote and preserve public health and upgrade
the standard of medical practice. In line with the DOH mandate, A
Manual on Hospital Management was published in 1997.
- The manual recommended color-coding scheme for segregated wastes to
avoid any accidents or hazards to personnel. The IRR also provides the
detailed sanitary requirements for the segregation, storage, collection,
transportation and disposal of refuse/solid waste.
Republic Act No. 8749
Clean Air Act of 1999
- Prohibits the incineration of biomedical wastes effective July 17, 2003.
- It promotes the use of state-of-the-art, environmentally sound, and safe
non-burn technologies for the handling, treatment, thermal destruction,
utilization and disposal of sorted, unrecycled biomedical hazardous
wastes.
Republic Act No.9003
Ecological Solid Waste Management Act, 2000
- Mandates the segregation of solid wastes (non-infectious wastes) at the
source including households and institutions like hospitals by using a
separate container for each type of waste from all sources (Section 21,
Art. 2)
Republic Act No.6969
An Act to Control Toxic Substances and Hazardous and Nuclear Wastes
- The waste generators (i.e., hospitals) are required to ensure that its
hazardous or biomedical waste is properly collected, transported, treated,
and disposed.
National Antimicrobial Stewardship (AMS) Program
- An integral component of the Philippine Action Plan to Combat
Antimicrobial Resistance (AMR), gives structure and direction to
healthcare facilities to adopt a proactive multidisciplinary approach to
rational antimicrobial use.
Republic Act No.9271
Quarantine Act of 2004
- The Bureau of Quarantine, being the health authority, is mandated to
ensure security against the introduction and spread of infectious diseases
to include the emerging diseases and public health emergencies of
international concern.
Republic Act No. 11332
Mandatory Reporting of Notifiable Diseases and Health Events of Public
Health Concern Act
- It shall endeavor to protect the people from public health threats through
the efficient and effective disease surveillance of notifiable diseases
including emerging and reemerging infectious diseases, diseases for
elimination and eradication, epidemics, and health events including
 chemical, biological, radioactive, nuclear and environmental agents of An infection occurs when germs enter the body, increase in number, and
public health concern and provide an effective response system in cause a reaction of the body.
compliance with the 2005 International Health Regulations (IHR) and its
amendments of the World Health Organization (WHO).

DOH Memorandum No.2020-0049

Reiteration of Interim Guidelines for 2019 Novel Corona Virus ARD
Response in Hospitals and other Health Facilities
- This is to provide guidance to all health facilities and institutions whether
public or private on the necessary precautions, preparations of health
facilities, and management of persons under investigation (PUI) and
confirmed cases of the 2019 –nCoV ARD.
DOH MEMORANDUM NO.2020-0327
SOURCE
Interim Guidelines on the Management of Patients and Delivery of Oral
Health Services during the Corona Virus Disease 2019 (Covid-19) An infectious agent or germ and refers to a virus, bacteria, or other microbe.
Pandemic
RESERVOIR
- All health facilities and providers of oral health services shall transition
into the New Normal in accordance with Administrative Order 2020- The habitat in which the agent normally lives, grows, and multiplies.
0015 Guidelines on the Risk-Based Public Health Standards for Covid- HUMAN RESERVOIR
19 Mitigation and Department Memorandum 2020-0268 Interim
Guidelines on Health Facilities in the New Normal. People are one source of germs (reservoir) including:

LESSON 2  Patients
 Healthcare workers
COMMUNICABLE DISEASES IN THE DENTAL SURGERY
 Visitors and household members
RESIDENT OR COMMENSAL FLORA
INDEX CASE
These bacteria live in harmony with our body and protect us by competing
A patient attending for dental treatment that can act as a source of infection
with other more harmful bacteria and thereby preventing colonization.
in an outbreak situation.
OPPORTUNISTIC PATHOGENS
FOUR STAGES OF INFECTION/COLONIZATION
Microbes that are considered commensal and harmless in healthy people
An index case may present one of the following:
which can cause infection if the host’s immune system is compromised (by
age, diseases or drugs).  Acute infection
HOW INFECTIONS OCCUR?  Prodromal stage of infection
  Convalescent or latent stage FACTORS THAT INCREASE SUSCEPTIBILITY
 Asymptomatic
 Underlying medical conditions
ENVIRONMENTAL RESERVOIR  Certain medications
 Medical treatments and procedures
Examples of Reservoirs in the healthcare setting:
THE CHAIN OF INFECTION
 Dry surfaces in patient care areas (e.g., bed rails, medical
equipment, countertops, and tables)
 Wet surfaces, moist environments, and biofilms (e.g., cooling
towers, faucets and sinks, and equipment such as ventilators)
 Indwelling medical devices (e.g., catheters and IV lines)
 Dust or decaying debris (e.g., construction dust or wet materials
from water leaks)
HEALTHCARE-ASSOCIATED INFECTIONS (HCAI)
Aka. Nosocomial infections
Infections that are acquired or emerge during treatment or inpatient stay.
 Infections are considered HCAI if they first appear 48 hours or more
after hospital admission or within 30 days after discharge.
PORTAL OF EXIT
TRANSMISSION
Is the pathway by which a pathogen leaves its host. The portal of exit usually
Refers to the way germs are moved to the susceptible person corresponds to the site where the pathogen is localized.
Direct PORTAL OF ENTRY
 Direct contact Refers to the manner in which a pathogen enters a susceptible host. The
 Droplet spread portal of entry must provide access to tissues in which the pathogen can
multiply or a toxin can act.
Indirect
ROUTES OF INFECTION IN A DENTAL PRACTICE
 Airborne
 Vehicleborne  Direct or indirect contact
 Vectorborne (mechanical or biologic via fomites)  Percutaneous (parenteral) transmission
 Air-borne route
SUSCEPTIBLE PERSON/ HOST
 Common vehicle
The final link in the chain of infection
Someone who is not vaccinated or otherwise immune, or a person with a
weakened immune system who has a way for the germs to enter the body.
  Rhinovirus - main cause of common colds
CONJUNCTIVITIS

• Adenoviridae/Herpes group
• S.aureus, S.pneumoniae, H.influenzae

IMPETIGO

• Grp.A Strep, S.aureus

CLOSTRIDIUM SPECIES

• causes GIT infections

MRSA causes the most concern especially in surgery

DISEASES SPREAD THRU DIRECT CONTACT
Direct contact is the most easily appreciated mode of infection spread caused
by dental professionals. The primary source of spread from person to person
is by hands and clothing.
DISEASES SPREAD THRU DIRECT/INDIRECT CONTACT
HERPES GROUP (HSV-1, HSV-2, VZV, EBV, CMV, EBV,
HSV-6, HSV-8)
 PRIMARY HERPETIC GINGIVOSTOMATITIS - initial
exposure to HSV-1, mild symptoms in children <10 years old.
 ACUTE HERPETIC GINGIVOSTOMATITIS - fever, irritability,
yellowish vesicles which ruptures into painful ulcers
 HERPES LABIALIS (COLD SORES) - most common site:
vermilion border
ORTHOMYXOVIRUS
Main mode of transmission: via the hands of HCW either by colonized or
infected patients or fomites.
PNEUMONIA
• STREP. PNEUMONIAE – most common cause of typical
pneumonia (lobar inflammation)
• HAEMOPHILUS INFLUENZAE – in children <2 yo
• KLEBSIELLA PNEUMONIAE – in alcoholics
DISEASES SPREAD THRU FLUIDS
• LEGIONNAIRE’S DISEASE, PONTIAC FEVER - Respiratory
infections from inhaling aerosols generated from the dental unit
waterline which are contaminated by Legionella bacteria.
• VIA THE DENTAL UNIT WATERLINES - Pseudomonas
aeruginosa (and MRSA are the most common cause of nosocomial
infections) can be resistant to some disinfectants and pose a risk to
immunocompromised patients.

 INFLUENZA A - pandemic and epidemics DISEASES SPREAD THRU PERCUTANEOUS TRANSMISSION

 INFLUENZA B - smaller, localized outbreaks
 INFLUENZA C - mild upper RT illness PARENTERAL HEPATITIS

PICORNAVIRIDAE • Hepatitis B (Hepadnaviridae)

• Hepa C (Flavivirus)
 Enteroviruses - Grp A Coxsakie (herpangina, hand-foot-and-mouth • Hepa D (Deltavirus)
disease)
 • Hallmark: jaundice caused by hepatic failure EBOLA VIRUS DISEASE (Africa 2014-2016)

HIV (AIDS) - progressive loss of T-helper cells (CD4 cells) • A severe, often fatal illness affecting humans and other primates
• The virus is transmitted to people from wild animals (such as fruit
DISEASES SPREAD THRU AIR-BORNE bats, porcupines and non-human primates) and then spreads in the
human population through direct or indirect contact
TUBERCULOSIS - (also via direct contact) Influenza.
• CA: Mycobacterium tuberculosis (spore forming, obligate aerobe, BOVINE SPONGIFORM ENCEPHALITIS
acid-fast bacilli)
• Most common respiratory disease in third world countries • MAD COW DISEASE (Prion Disease) - spongy degeneration of
the brain with severe and fatal neurological signs and symptoms
• Primary (Ghon) complex: granuloma + hilar lymph node • VARIANT CREUTZFELDT-JAKOB DISEASE (VCJD) - As of
2019, 232 people worldwide are known to have become sick with
PANDEMIC INFLUENZA - Influenza A subtype H1N1 (swine flu). vCJD, and unfortunately, they all have died.
Developed during 2009-2010
SARS-CoV
EMERGING AND RE-EMERGING PATHOGENS
• Thought to be an animal virus from an as-yet-uncertain animal
1. Infections can emerge via a variety of different processes: reservoir, perhaps bats, that spread to other animals (civet cats) and
1. Novel pathogens arising de novo first infected humans in the Guangdong province of southern China
2. Known infections spreading to new geographic area or population in 2002
3. Previously unreported infections appearing in areas undergoing • An epidemic of SARS affected 26 countries and resulted in more
climate change. than 8000 cases in 2003.
4. Old infections re-emerging as a result of changes in host immunity, • Most cases of human-to-human transmission occurred in the health
antimicrobial selection and resistance or breakdowns in public health care setting, in the absence of adequate infection control precautions.
measures
MERS-CoV (Saudi Arabia, 2012)
ZOONOTIC INFECTIONS - Transmission of infection from animal to
humans through a number of different routes, including direct contact with • MERS-CoV likely came from an animal source (camels) in the
the living animal, their meat or secretions or vector transmission via insect Arabian Peninsula.
bites. • MERS-CoV, like other coronaviruses, likely spreads from an
infected person’s respiratory secretions, such as through coughing.
ZOONOTIC INFECTIONS CoViD-19(Wuhan, China, December 2019)
• Rabies • Current evidence suggests that COVID-19 spreads between people
• Ebola virus disease through direct, indirect (through contaminated objects or surfaces),
• Bovine spongiform encephalitis (mad cow disease) or close contact with infected people via mouth and nose secretions.
 Variant Creutzfeldt-Jakob disease • People who are in close contact (within 1 metre) with an infected
• Novel corona virus infections person can catch COVID-19 when those infectious droplets get into
 SARS-CoV their mouth, nose or eyes.
 MERS-CoV
 CoViD-19
LESSON 3
OCCUPATIONAL HEALTH AND IMMUNIZATION

Occupational Health is a multi-disciplinary activity aimed at: 

 The protection and promotion of the health of workers by preventing 

and controlling occupational diseases and accidents and by 
eliminating occupational factors and conditions hazardous to health 
and safety at work. 
 The development and promotion of healthy and safe work, work 
environments and work organizations
 The enhancement of the physical, mental and social well-being of 
workers and support for the development and maintenance of their 
working capacity, as well as professional and development at work; 
 Enabling workers to conduct socially and economically productive
lives  and to contribute positively to sustainable development.

OCCUPATIONAL HEALTH HAZARD

The six primary hazard categories are:

 Physical hazards 
 Chemical hazards 
 Biological hazards 
 Radiological hazards 
 Ergonomic hazards 
 Behavioral hazards Building a Culture of Safety
 R.A. 11058 

Occupational Safety and Health Standards Act or  the Republic Act 
 Signed into law by President Rodrigo Roa Duterte on 17  August
2018 
 Mandates strict compliance of employers to workplace safety
standards

Department Order No. 198 S.2018 (DOLE)

 Implementing Rules and Regulations of RA 11058

Department Order No. 198 S.2018

 the practice management takes to improve patient and  dental
personnel safety 
 All the members of the dental team participating in safety  planning
and infection control protocol development
 Influence of group norms regarding acceptable safety practices
 Routine and occupational immunization, postexposure 
prophylaxis, availability of appropriate personal protective 
equipment and training in its correct use 
 Induction training and socialization process for new dental 
personnel or students

Error Traps 

 Mistakes and accidents that tend not to  random mishaps but fall into
recurrent  patterns
 Breakdowns in the practice’s infection control  management and
‘defenses’ can arise from  two main causes: 
 Active Failures
 Latent Conditions
Steps in creating a safety culture: Active Failures 
 Unsafe acts committed by frontline people in  direct contact with the
patient. 
 A
c  Their impact is usually instantaneous and  breaches the integrity of
ti practice’s ‘defenses’
o Latent Failures 
n  Arise from decisions made on the design, procedures and
s management within the  practice or may relate to decisions taken  
outside the dental practice by third parties,  such as equipment and
instrument  manufacturers or governmental organizations

Where latent failures could occur in dental practice 

 Poor design of surgery and equipment
 Ineffective training 
 Inadequate supervision 
 Ineffective communications 
 Uncertainties in roles and responsibilities

Root cause analysis 

The aim of root cause analysis is to determine: 
 What happened 
 Why it happen
  What can be done to prevent it from happening again sensory ganglion (dorsal root and trigeminal) but can reactivate later
in life as shingles.
Organizing Staff Health in Dental Practice 
 Everyone working in the practice has a duty of care  towards the
patients, which includes taking  reasonable precautions to protect
them from  communicable diseases.

Immunization 
 Immunization is the process whereby a person  is made immune or
resistant to an infectious  disease, typically by the administration of
a  vaccine.
 Pre‐employment health clearance,  evaluation of immunization status
and  eligibility for vaccinations according to the  national schedule
are normally managed by  an occupational health service provider.

Failure to Report Accidents 

 Underreporting of sharps and splash incidents  is a common
phenomenon in healthcare.

 Failure to report accidents, incidents and near  misses is often

due to: 
 fear of being accused of negligence  Varicella vaccine
 fear of being labelled accident prone   live attenuated vaccine (Varicella Vaccine Zoster)
 damage to reputation with peers  Testing:
 conflict of loyalty to the patient or the practice  Polymerase chain reaction (PCR) test
 fear of subsequent medical treatment, e.g. postexposure  Recommended for:
prophylaxis   seronegative/ all non-immune dental workers who have direct or
 fear of exclusion from work  regular patient contact
 lack of understanding of purpose of accident reporting. Dosing schedule: Two doses 4-8 weeks apart
Contraindication: Pregnancy
Immunization Requirements for Dentistry 
 Varicella live attenuated vaccine RUBELLA
 MMR vaccine Incubation period: 14-21 days
 BCG vaccine Primary infection:
 Hepatitis B vaccine (inactivated)  low-grade fever, malaise and mild conjunctivitis erythematous rash
 Quadrivalent vaccine (Trivalent vaccine) on ears, face and neck Person is infectious from 1 week before
symptoms appear to four days after the onset of rash.
VARICELLA MMR vaccine
Incubation period: ranges from 10-21 days  Live attenuated vaccine
Primary infection: Recommended for:
 itchy blisters/rash on the skin (children) fever/malaise 1-2 days  All dental workers unless documented evidences of MMR, or
before rash onset (adult) The virus eventually becomes latent in the positive antibody tests for measles and rubella (IgG antibody testing)
Dosing schedule: BCG (bacille Calmette-Guerin) vaccine
 Two doses Contraindication: Pregnancy, allergy,  Live attenuated vaccine (Mycobacterium bovis)
immunosuppression Recommended for:
 All dental workers with close patient contact (unvaccinated,
TUBERCULOSIS tuberculin-negative)
Incubation period: 2-12 weeks Dosing schedule:
Primary infection:  Single dose Contraindication: immunosuppression, allergy,
 Ghon complex pregnancy
General symptoms: Chemoprophylaxis:
 Fever, fatigue, weight loss, night sweats and persistent cough more  6 months of isoniazid or 3 months isoniazid/rifampicin
than 3 wks
Most common form: Pulmonary TB  R ifampicin (Rifampin)
Testing:  I soniazid
 Mantoux tuberculin skin test (TST) Interferon Gamma Release  P yrazinamide
Assay (IGRA)  E thambutol
 S treptomycin

HEPATITIS B
Incubation period: 60-150 days
General symptoms:
 Asymptomatic or if present, fever, fatigue, loss of appetite, n&v,
abdominal pain, clay colored stool, joint pain and jaundice
Testing:
 Hepatitis B surface antigen (HBsAg)
 Hepatitis B surface antibody (HBsAb/ anti-HBs)
 Hepatitis B core antibody (HBcAb/anti-HBc)

Hepatitis B vaccine
 Subunit vaccine
Recommended for:
 All dental workers with close contact with blood with no evidence of
previous immunization/disease
Dosing schedule: 3-4 doses, booster at 5 years
Contraindication: allergy
PEP: HBIg (Hepatitis B Immune globulin)

INFLUENZA
Incubation period: 1-4 day
  EPPs include procedures where the worker’s gloved hands may be in
contact with sharp instruments, needle tips or sharp tissues inside a
patient’s open body cavity, wound or confined anatomical space
where the hands or fingertips may not be completely visible at all
times.

CATEGORY DEFINITION ASSOCIATED EXAMPLES

RISK OF
PROCEDURE
1 Hands and Low Local anesthetic
fingertips are injections,
visible most of polishing of
the time & slight teeth or
Trivalent/Quadrivalent vaccine possibility of restorations
 Inactivated/recombinant vaccine injury to
Recommended for: worker’s gloved
 All dental workers directly involved with patient care hands
Dosing schedule: single dose 2 Fingertips may Intermediate Tooth
Contraindication: allergy not be visible at extraction,
all times; injury Root canal
SYPHILIS is unlikely therapy
 Dentists should refer any patients with suspicious lesions of either 3 Fingertips are Highest Osteotomy
primary syphilis (presenting as chancre) or secondary syphilis out of sight
(presenting as oral ulceration and/or mucosal lesions) to the patient’s for a significant
medical practitioner or their local sexual health clinic. part of
Syphilis Prophylaxis procedure,
PEP: Penicillin G distinct risk of
Exposure-Prone Procedures “Bleed-Back” injury
Non- EPP Hands and None (provided Incision of
fingertips are IPC external
visible at all procedures are abscesses,
times; do not adhered to at all taking
involve possible times) impressions
injury
HEALTH CLEARANCE
 All dental healthcare workers who perform EPPs (such as dentists,
therapists and hygienists) must have pre‐employment additional
health checks that are to be completed prior to confirmation of their
post.
HIV+ HCW are permitted to treat patients undergoing EPPs as long as  In the dental surgery, the most common route for transmission of a BBV
they comply with: infection is from an infected patient to a clinician.

 On effective cART (combination antiretroviral treatment) Risks of Seroconversion due to Sharps Injury
 Be subject to plasma viral load monitoring every three months
 Be under supervision of physician/occupational health physician

R.A. 8504
Philippine AIDS Prevention and Control Act of 1998
 An act promulgating policies and prescribing measures for the
prevention and control of hiv/aids in the philippines, instituting a
nationwide hiv/aids information and educational program,
establishing a comprehensive hiv/aids monitoring system,
strengthening the philippine national aids council, and for other
purposes

Department Order No. 102-10 S.2010

 Guidelines for the Implementation of HIV and AIDS Prevention and
Control in the Workplace Program
 Workplace Policy and Program shall include, among others, the ff:
Advocacy, Information, Education and Training
Social Policies
Diagnosis and Treatment, and Referral for Other Services

Duty of Care to Patients

 Dentists and other dental health personnel who believe that they may
have been exposed to BBV are under a legal, professional and ethical
obligation to promptly seek and follow confidential advice on testing
for BBV and national guidelines on practicing restrictions

LESSON 4
Sharp Safe Working in the Dental Surgery
Sharps Injury
 refers to any injury or puncture to the skin involving a sharp instrument,
such as a dental bur, syringe needle or suture needle
Why sharps prevention is important?
 Sharps injuries and splashes to eyes or broken skin can transmit BBV
infections.
The actual risk of seroconversion depends on:

 Prevalence of the infection in the local population.

 How infectious the patient is.
 Whether the dental treatment or task is likely to result in a sharps injury
or splash
 Type of exposure and the type of virus (WHO)
 Nature and frequency of blood exposures (WHO)

How to avoid sharps injury?

 SAFE HANDLING OF SHARPS

 USE OF SAFETY SHARPS
 SHARP SAFE DISPOSAL

Use of Safety Sharps

 Safety needles with integrated retractable sheath  Safety scalpels
 The sheath can be retracted whenever the needle is required to give  Scalpels that have a covering around the blade that covers the blade
an injection and is then slid down over the needle, protecting the until it is used. Safety scalpels help prevent accidental contact with
operator between use and during dismantling and disposal.

Use of Safety Sharps

 DISPOSABLE SCALPELS
 Single-use scalpels that commonly use a plastic handle connected to
a surgical blade

the surgical blade.

Sharp Safe Disposal
1. Single-use sharps should be discarded immediately after use by the user.
2. Never leave sharps on the bracket table to be disposed of by someone
else
3. Use disposable safety scalpels and syringes.
  Exposure reporting
 Assessment of infection risk
 Appropriate treatment, follow-up, and counseling

Wound Management
 Clean wounds with soap and water
 Flush mucous membranes with water
 No evidence of benefit for:
– application of antiseptics or disinfectants
– squeezing (“milking”) puncture sites
 Avoid use of bleach and other agents

The Exposure Report

 Date and time of exposure
 Procedure details…what, where, how, with what device
 Exposure details...route, body substance involved, volume/duration of
contact
 Information about source person and exposed person

Assessment of Infection Risk

 Type of exposure
 Body substance
 Source Person (blood-borne infection status)

Evaluating the source

7. Ensure that the sharps bin is correctly assembled and that the lid is
 Informed consent should be obtained in accordance with state and local
securely fastened before use.
laws
8. Place bins conveniently close to the point of use.  Confidentiality of the source person
9. Do not place sharps bin on the floor, on an unstable surface or above
Unknown or Untestable Source
shoulder height.
 Consider information about exposure
10. Keep the aperture closed when the sharps bin is not in use. - where and under what circumstances
- prevalence of HBV, HCV, or HIV in the population group
11. Seal and dispose of when three-quarters full.
12. Never try to retrieve ay items from a sharps bin. Management of Hepatitis C Exposures
 Baseline evaluation and testing
Managing Sharps Injuries and Splashes  Follow-up testing and counseling
 Wound management  PEP Not recommended after exposure
 - immunoglobulin not effective • Baseline evaluation and testing of exposed person
- no data on use of antivirals (e.g., interferon), and may be effective • Consideration of treatment
only with established infection – when to give
- antivirals not FDA approved for this setting – what to give
– pregnancy in exposed
Postexposure counseling for HCV • Follow-up testing and counseling
 Refrain from donating blood, plasma, organs, tissue, or semen.
 No need for: Baseline HIV testing
- modification of sexual practices or refraining from becoming • Enzyme-Linked Immunosorbent Assay(EIA/ELISA) standard test
pregnant or breastfeeding • Direct virus assays not recommended
- modification to patient care responsibilities for exposed person  p24 antigen
Management of Hepatitis B Exposures  PCR for HIV RNA
 Baseline evaluation and testing of exposed person with unknown PEP for HIV
HBV immune status
 Consideration of treatment • For optimal efficiency, HIV PEP should be initiated within1-72
when to give hours after exposure
what to give Combination AntiRetroviral Therapy (cART)
 Follow-up testing and counseling ZIDOVUDINE (backbone component of cART),
didanosine, nevirapine
PEP for HBV  Consider re-evaluation of the exposed person within 72 hours
 Highly effective within 48 hours after exposure if the source person has a negative HIV antibody test, stop
Unvaccinated HBIG x 1 and initiate hepatitis B vaccine series PEP
Previously vaccinated Studies of HIV PEP Prevention on Perinatal Transmission
Test exposed person for anti- HBs  ZDV administered during pregnancy, labor, and delivery reduced
1. If adequate, no treatment transmission by 67% (Connor EM,et al. N Engl J Med
2. If inadequate, HBIG x 1 and vaccine booster 1994;331:1173-80.)
 Protective effect observed when ZDV given only to newborn within
Postexposure counseling for HBV the first 48-72 hours of life (Wade NA, et al. N Engl J Med
Refrain from donating blood, plasma, organs, tissue, or semen. 1998;339:1409-14.) ( Musoke P, et al. AIDS 1999;13:479-86.) (Guay
LA, et al. Lancet 1999;354:795-802.)
 No need for:
– modification of sexual practices or refraining from becoming Current stand of CDC
pregnant or breastfeeding
– modification to patient care responsibilities for exposed person After birth, babies born to a mother with HIV are given ART right away for 4
 If acute HBV infection, evaluate according to published to 6 weeks. If you are treated for HIV early in your pregnancy, the risk of
recommendations transmitting HIV to your baby can be 1% or less. Breast milk can have HIV
in it. So, after delivery, you can prevent giving HIV to your baby by not
Management of HIV Exposures breastfeeding.
Follow up HIV Testing  Resident flora has two main protective functions: microbial
antagonism and the competition for nutrients in the ecosystem
 If source HIV positive, test at 6 weeks, 3 months, 6 months
 Staphylococcus epidermidis is the dominant species
EIA standard test
 Extending follow-up to 12 months TRANSIENT FLORA
recommended for HCP who become infected with HCV
 Transient flora, which colonizes the superficial layers of the skin, is
following exposure to co-infected source
more amenable to removal by routine handwashing.
HIV Postexposure counseling  They are often acquired by HCWs during direct contact with patients
or contaminated environmental surfaces adjacent to the patient, and
 Side effects of PEP drugs
are the organisms most frequently associated with health care-
 Signs and symptoms of acute HIV infection associated infections (HCAIs).
fever, rash, flu-like illness
 Prevention of secondary transmission HAND HYGIENE
sexual abstinence or condom use
 The main purpose of hand hygiene is to remove or destroy the
no blood/tissue donation
transient flora acquired through contact with patients and their
 Transmission and PEP drug risks if breastfeeding
surroundings or contaminated equipment, as well as the physical
 No work restriction indicated removal of dirt, blood and body fluids.
Recommendations for Dental Clinic Hand hygiene is the single most important method of reducing cross-
 Establish a bloodborne pathogen management policy transmission of infectious organisms (Loveday et al., 2014)
 Implement management policies (e.g., training, hepatitis B WHEN TO CLEAN HANDS?
vaccination, exposure reporting, PEP access, etc.)
 Establish laboratory capacity for bloodborne virus testing 1. Before touching a patient
 Select and use appropriate PEP regimens 2. Before clean/ a septic procedure
 Provide access to counseling for exposed personnel 3. After body fluid exposure risk
4. After touching a patient
 Monitor adverse events and seroconversion
 Monitor exposure management programs
LESSON 5
HAND HYGIENE
Skin of the hand harbours two main types of microorganisms, resident and
transient, which colonize and survive on the hands for differing amounts of
time.
RESIDENT FLORA

 Microorganisms residing under the superficial cells of the stratum

corneum, and can also be found on the surface of the skin.
 5. After touching patient’s surrounding  Active against C.difficile, but weak against G(-) bacilli
 May cause irritant/allergic dermatitis and can cause alterations in
HAND HYGIENE PRODUCTS thyroid and reproductive systems
 The term ‘hand hygiene’ encompasses traditional hand washing with
IODINE AND IODOPHORS
soap and water or antiseptic hand washes and the newer technique of
 Rapid action
hand rubbing with disinfectant, alcohol‐based hand rubs (ABHR)
that do not require running water.
PLAIN SOAP

 Soaps are detergent-based products that contain esterified fatty acids

and sodium or potassium hydroxide.
 Their cleansing activity can be attributed to their detergent
properties, which result in removal of lipid and adhering dirt, soil
and various organic substances from the hands.
 Has minimal antimicrobial property
ANTIMICROBIAL SOAP

 Soap (detergent) containing an antiseptic agent at a concentration

sufficient to inactivate microorganisms and/or temporarily suppress
their growth. The detergent activity of such soaps may also dislodge
transient microorganisms or other contaminants from the skin to • Active against C.difficile
facilitate their subsequent removal by water • Inhibited by organic material
• May cause irritant/allergic dermatitis and staining of skin
CHLORHEXIDINE
 The antimicrobial activity of chlorhexidine appears to be attributable
QUATERNARY AMMONIUM COMPOUNDS
to the attachment to, and subsequent disruption of cytoplasmic
• Eg. Benzalkonium chloride
membranes, resulting in precipitation of cellular contents
• Slow action
 Rapid action
• Active against C.difficile
 Binds to skin
• •Primarily bacteriostatic and fungistatic, although they are
 Remains active for up to 6 hours
microbicidal against some organisms at high concentrations
 Active against C.difficile, but not sporicidal
• Inhibited by organic material
 May cause irritant/allergic dermatitis
• May cause irritant/allergic dermatitis
TRICLOSAN
CHLOROXYLENOL
 It has been incorporated into soaps for use by HCWs and the public
• Also known as para-chloro-meta-xylenol (PCMX), is a halogen-
and into a variety of other consumer products.
substituted phenolic compound that has been used widely as a
 Rapid action preservative in cosmetics and other products and as an active agent
 Binds to skin in antimicrobial soaps.
 Remains active for up to 6 hours • Slow action
 • Further evaluation of this agent by the FDA is ongoing
HEXACHLOROPHENE
• Emulsions containing 3% hexachlorophene were widely used for
hygienic handwashing, as surgical scrubs, and for routine bathing of
infants in hospital nurseries
• Banned worldwide because of its high rates of dermal absorption and
subsequent toxic effects
• Emulsions containing 3% hexachlorophene were widely used for
hygienic handwashing, as surgical scrubs, and for routine bathing of
infants in hospital nurseries
• Banned worldwide because of its high rates of dermal absorption and
subsequent toxic effects
alcohol are most effective, with higher concentrations being less
potent
• Inhibited by organic material
The efficacy of alcohol-based hand hygiene products is affected by a number
of factors, including the type of alcohol used, the concentration of alcohol,
the contact time, the volume of alcohol used, and whether the hands are wet
when the alcohol is applied.
ALCOHOL-BASED HAND RUBS (ABHR)
• is the preferred method for cleaning your hands when they are not
visibly dirty because it:
o Is more effective at killing potentially deadly germs
o Is easier to use during the course of care, and
o Improves skin condition with less irritation and dryness than
soap and water

ALCOHOL
• The antimicrobial activity of alcohols results from their ability to
denature proteins
• Very rapid
action
• Short-lived HAND HYGIENE PRACTICES
• Alcohol  Hand hygiene is used in three circumstances:
solutions o hand washing (social hand hygiene),
containing o Hand disinfection using an ABHR (hygienic hand hygiene)
60–80% o Surgical scrub (surgical hand hygiene)

FREQUENTLY MISSED AREAS

 Fingertips
 • Applying an antiseptic handrub to reduce or inhibit the growth of
microorganisms without the need for an exogenous source of water
and requiring no rinsing or drying with towels or other device

HANDRUBBING TECHNIQUE

SURGICAL SCRUB
• Antiseptic handwash or antiseptic handrub performed pre-operatively
by the surgical team to eliminate transient and reduce resident skin
flora.

GENERAL GUIDELINES FOR HAND HYGIENE

 Interdigital areas • A poster showing hand-washing protocol should be displayed in
 Thumbs surgery.
 Wrists • Cuts and abrasions less than 24 hours old must be covered with a
waterproof dressing.
• Fingernails should be kept short, clean and free from nail polish,
artificial nails and nail art.
• Wristwatches and jewelry should be removed, and any long-sleeved
clothing should be rolled up/removed.
• Hand cream should be applied regularly throughout the day to
HANDWASHING
protect skin from drying.
• Washing hands with plain or antimicrobial soap and water
 Petroleum-based hand creams are not recommended as they
can adversely affect latex, thereby increasing glove
HANDWASHING TECHNIQUE
permeability, which in turn permits ingress of micro-
organisms.
ANTISEPTIC HANDRUBBING

 Hand wash sink and surrounds should be visibly clean and free of
clutter.
 The sink should be easily accessible and must be dedicated for hand
washing only.
 Taps should be preferably sensor, elbow-, or foot operated lever taps
 Water jet should not flow directly into the plughole.
 A choice of wall-mounted dispensers of liquid soap, aqueous
detergent and ABHR should be provided. Soap bars are not
recommended for use in clinical setting.
 Hand hygiene solutions should be dispensed in disposable rather than
refillable cartridges/bottles. Keep the dispenser nozzle clean.
 Wall-mounted disposable paper towels should be used.
 Dispose of the used towels in foot-operated waste bins.
 Nail brushes are not indicated for hand hygiene. Use sterile brush.
 Patients on entering and exiting treatment area should be encouraged
to clean their hands.
LESSON 6
PERSONAL PROTECTION FOR PREVENTION OF CROSS
INFECTION
Objectives
 to provide information on the selection and use of PPE in healthcare
settings
 to practice the correct way to don and remove PPE
PERSONAL PROTECTIVE EQUIPMENT
 Personal protective equipment, or PPE, as defined by the
Occupational Safety and Health Administration, or OSHA, is
“specialized clothing or equipment, worn by an employee for
protection against infectious materials.
AREAS OF THE BODY CONTAMINATED DURING PROCEDURES
 Forearm
• Upper chest
• Face
Selection of the most appropriate PPE must be based on a risk assessment of
the associated hazards and likelihood and route of transmission of
microorganisms from the source.
Personal protective equipment will function effectively ONLY IF selected,
worn, removed and discarded correctly.
THE ROLE OF GLOVES
• Gloves are single use and should be worn for all routine dental
treatment
• When used correctly, wearing gloves:
 Protects hand from contamination with blood, saliva and
microorganisms
 Reduces the risk of cross-infection
 Protects hands from toxic and irritant chemicals
 Lowers risk of BBV transmission due to wiping effect
SAFE USE OF GLOVES
• Hands must be washed before and after donning gloves
• Change gloves between patients
• Never touch other surfaces with gloved hands
• Never reuse single-use disposable gloves
• Never wash or disinfect single-use gloves
• Keep glove wear to a minimum
• Change gloves during long procedures
• Dispose of gloves as hazardous infectious waste
• Practice hand hygiene after doffing of gloves
 • Multipolymer synthetic styrene-ethylene-butadine- styrene), e.g.
NATURAL RUBBER LATEX (NRL) Tactylon
• Impermeable to BBV • Similar strength and elasticity to NRL
• Close fitting • Suitable if allergic to NRL/Nitrile
• Do not impair dexterity and not prone to splitting
• Resistant to water-based chemicals POLYTHENE
• Causes skin allergies • Permeable, ill-fitting and prone to splitting and tearing
• Not suitable for clinical use
NITRILE (ACRYLONITRILE)
• Impermeable to BBV Reactions to NRL or accelerating agents
• Close fitting
• Do not impair dexterity and not prone to splitting (lowest failure DELAYED HYPERSENSITIVITY (TYPE IV)
rate) • resulting in contact dermatitis, rhinitis and conjunctivitis
• Resistant to solvents and oil-based chemicals • most common hypersensitivity reaction to NRL or accelerating
agents
LATEX VS NITRILE • occurs between six and 48 hours after exposure

POLYCHLOROPRENE (NEOPRENE) IMMEDIATE HYPERSENSITIVITY (TYPE I)

• Impermeable to BBV
• Suitable if allergic to NRL

VINYL
• Impermeable to BBVs
• Has similar properties to NRL when made to European standard
• Suitable if allergic to NRL/Nitrile

CO-POLYMER

• Asthma, urticaria, laryngeal edema, anaphylactic shock

• Occurs 15-30 mins after exposure

RESPIRATORY PROTECTIVE EQUIPMENT
• Respiratory protective equipment (RPE) is required against
organisms that are usually transmitted via the droplet/ air‐borne
route, or when air‐borne particles have been artificially created, such
as during ‘aerosol‐generating procedures’
• Masks are single‐use items.
• Mask should be disposed of immediately after use as hazardous
clinical infectious waste
• Do not pull the surgical mask or respirator mask down to hang
around the neck or wear on the elbow
• Hands should be cleaned after removing the mask

SURGICAL MASKS
• A loose-fitting, disposable device that creates a physical barrier
between the mouth and nose of the earer and potential contaminants
in the immediate environment

RESPIRATOR MASKS
• Used during the care of patients with respiratory infections
transmitted by air-borne particles
• Contraindicated for use in persons with heart conditions, lung
disease, and psychological conditions ie. Claustrophobia

N95 RESPIRATOR

• Respiratory protective device designed to achieve a very close facial

fit and very efficient filtration of airborne particles

ELASTOMERIC RESPIRATOR
AMERICAN SOCIETY FOR TESTING AND MATERIALS (ASTM)
• The facepieces are made of synthetic or natural rubber material, can
be repeatedly used, cleaned, disinfected, stored, and re-used
 Half-face Respirator
 Full-face Respirator
SAFE USE OF SURGICAL MASKS
POWDERED AIR-PURIFYING RESPIRATOR
• Masks are recommended for all dental procedures
• An air-purifying respirator that uses a blower to force air through
• Masks should be close fitting and cover the nose and mouth
filter cartridges or canisters and into the breathing zone of the
• Avoid touching the outer filtering surface of the mask wearer. This process creates an air flow inside either a tight-fitting
• Only handle the ties/ear loops facepiece or loose-fitting hood or helmet
 RESPIRATORY HYGIENE

PROTECTIVE EYEWEAR AND VISORS

• The clinical dental team must protect their own eyes and those of the
patient against respiratory secretions, splatter, aerosols and foreign
• A PAPR can be used for protection during healthcare procedures in bodies such as amalgam fragments. Eye protection is always required
which HCP are exposed to greater risks of aerosolized pathogens during potentially infectious aerosol‐generating procedures.

GOGGLES
• Appropriately fitted, indirectly -vented goggles* with a
manufacturer’s anti-fog coating provide the most reliable practical
eye protection from splashes, sprays, and respiratory droplets

VISORS/FACE SHIELDS
• Best worn where there is a risk of blood or body fluid splattering or
spraying of potentially infectious material as they provide full face
protection
causing acute respiratory infections. • To provide better face and eye protection from splashes and sprays, a
face shield should have crown and chin protection and wrap around
FITTING AND WEARING OF A RESPIRATOR MASK the face to the point of the ear
• When fitted and worn correctly, respirators seal firmly to the face,
thus reducing the risk of leakage. SAFE USE OF GOGGLES AND VISORS
• A facial seal check should be performed by the wearer of a respirator
each time it is donned
• Note that beards and stubble interfere with the fit and seal of the
respirator
• Avoid touching the outer surface of the respirator mask once it is
fitted.
• Always clean hands after handling the mask.
• Dispose of as hazardous infectious clinical waste.
 • Goggles with side protection or face shields should be worn during
all types of dental treatment or when manually cleaning instruments
• Single‐use disposable goggles and visors are preferred but reusable
goggles and visors should be decontaminated
• Goggles should not impair the operator’s vision
• Careful fitting of eyewear and masks before patient contact avoids
the need to make further adjustments
taken to avoid touching the outer surface of the apron during
wear or disposal
DISPOSABLE ARM SLEEVES
 Can be worn to cover forearm during patient treatment
 Single-use items, must be changed between patients and disposed an
infectious clinical waste

TUNICS AND UNIFORMS SURGICAL GOWNS

• Tunics and uniforms are not PPE
 If there is a risk of splashing with blood or body fluid onto skin or
• Ties and dangling necklaces should not be worn when treating
clothing such as during minor oral surgery, periodontal or implant
patients
surgery then disposable, long‐sleeved fluid‐repellent surgical gowns
• High-necked tunics and uniforms that cover the upper chest area is
advised are advised
• Work ‘bare below the elbows’ COVERALLS

WEARING AND CLEANING OF WORKWEAR  Coveralls without integrated hoods are preferred; coveralls with or
• Uniforms should be changed daily without integrated socks are acceptable
• Remove protective clothing when eating and drinking
• Tunics and uniforms should be removed before leaving the practice
and placed in an impermeable bag
• Tunics/uniforms should be washed separately from household wash
• Iron the uniform

PROTECTIVE BARRIERS
• protect the skin and/or clothing from microbial contamination
 Disposable plastic aprons
 Disposable ‘sleeves’
 Sugical gowns
 Coveralls

PLASTIC APRONS

• Considered suitable for general clinical use, manual instrument

cleaning or mopping up body fluid spills
• Classified as single-use items and should be changed between
patients or each procedure and then discarded as hazardous clinical
waste.
• They are prone to develop static electric charge in use, which attracts
increased numbers of bacteria onto the apron. So, care should be
 PERSONAL PROTECTION FOR PREVENTION OF CROSS
INFECTION
Donning Protective Equipment
1. Perform hand hygiene
2. Plastic Apron (or Fluid-repellent gown)
3. Surgical mask (or respirator mask)
4. Protective eyewear
5. Gloves
DONNING GLOVES

• Select correct type of glove and size

• Extend to cover wrist, over isolation gown if worn
• Sequence of PPE donning, gloves are often the last item to be put
on

BOOT COVERS AND SHOE COVERS

 Reduce contamination of shoes and floors

 Boot and shoe covers (if the latter are used) should allow for ease of
movement and must not present a slip hazard to the wearer
LESSON 6.2
DONNING SURGICAL MASKS WITH EAR LOOPS
DONNING TIE-ON SURGICAL MASKS
DONNING RESPIRATOR MASKS

DONNING GOGGLES OR FACE SHIELD

DONNING OF GOWN
 Fully cover torso from neck to knees, arms to end of wrists, and wrap
around the back.
 • Fasten in back of neck and waist
COVID-19 Guidelines on Donning PPE

DONNING OF COVERALLS

DOFFING PROTECTIVE EQUIPMENT

1. Gloves
2. Plastic apron or gown
3. Protective eyewear
4. Surgical or respirator mask
5. Perform hand hygiene

DOFFING OR GLOVES

DOFFING OF GOWNS
1. Unfasten gown
2. Pull away from neck and shoulders, touching inside of gown only
3. Turn gown inside out
4. Fold or roll into a bundle and discard

DOFFING GOGGLES AND FACE SHIELD

1. Remove from the back by lifting the head band over the ear piece
2. Place in designated area for reprocessing or disposal

DOFFING RESPIRATOR OR SURGICAL MASK