5. infection control in omfs(71) Dr. RAHUL TIWARI

INFECTION CONTROL IN OMFS

Dr. Rahul Tiwari – 2nd Yr. MDS – PG Student.Department of Oral & Maxillofacial Surgery.

05/02/2023 RT/5/INFECTION CONTROLL IN OMFS/72 1

PRESENTING SEMINAR ON

CONTENTS

INTRODUCTION HISTORICAL RELEVANCETRANSMISSION OF INFECTION MODE OF TRANSMISSIONINFECTION CONCERN IN OMFSOBJECTIVES OF INFECTION CONTROLPERSONAL BARRIER PROTECTIONEMERGENCY & EXPOSURE INCIDENT PLANOPERATORY ASEPSIS


DISINFECTIONINSTRUMENT HANDLING & CLEANINGSTERILIZATIONMONITORS OF STERILIZATONSTORAGE OF STERILIZED ITEMS HANDPIECE ASEPSISCLINICAL WASTE DISPOSALCONCLUSION & REFERENCES.


CONTENTS

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Introduction Our bodies are amazing structures that defend us against infections under normal circumstances.

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Body’s DefensesImmunity – resistant to pathogens and the disease they cause

If defenses are not functioning properly, person will become susceptible to invasion and infection.

Lines of DefenseSkin Normal floraStaying healthy


INTRUDING BODY’S LINE OF DEFENSE

During any operative procedure, we are breaching body’s line of defense

Sterilization , Disinfection and Asepsis becomes important05/02/2023 RT/5/INFECTION CONTROLL IN OMFS/72 6


History of Infectious Disease Prevention 3,000 BC – Egyptians use antiseptics such as

pitch or tar, resins and aromatics.

550 BC, Greek Infantry men known as hoplite

sometimes fought naked, pieces of clothing

carried into a wound by a penetrating sword or

spear point were more likely to cause infection.

460-377 BC Hippocratus used wine or boiled

water, for asepsis.

Holmes and Sommelweis

HolmesDemonstrated that fever was carried from patient to patient by doctors.

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Sommelweis Also concluded

fever was a communicable disease.

The Hungerian Obstetrician Sir IGNAZ SOMMELWEIS & OLIVER HOLMES laid down general principles of asepsis

Made hand washing compulsory before any operative procedure


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Joseph Lister

Discovered how to use chemical antiseptics to control surgery related infections

Used antiseptics to disinfect surgical equipment and supplies

FATHER OF ANTISEPTIC SURGERY05/02/2023 RT/5/INFECTION CONTROLL IN OMFS/72

Joseph Lister

Lister began washing his hands before operating, and wearing clean clothes.

Lister also sprayed the air with carbolic acid to kill airborne germs.


130-200 AD Galen A Greek distinguished physician boiled

instruments used in caring for wounds

1683, Anton van Leeuwenhoek, invents the microscope and

proves the existence of microorganisms.

1758 – the earliest recorded instance of the use of surgical

glove- Dr. Johann Julius Walbaum formed a glove from the

intestines of a sheep and used it to deliver babies

Indian connection-CHARAKA & SUSHRUTA used Boiling Water

(Ocimum sanctum, Mangifera Indica, Neem neem)


DEFINITIONSSTERILIZATION: Use of a physical or chemical

procedure to destroy all microorganisms including substantial numbers of resistant bacterial spores.

Sterilization means the destruction of all life forms. (Ronald B

Luftig)Sterilization is the process of killing or removing all

viable organisms. (MIMS –

PLAYFAIR)


Ref : C.P BAVEJA, Text book of microbiology, pg:-20-22,2nd edition, 2006Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-4-6, 3rd edition, 2005Ref ; Daniel M. Laskin, oral and maxillofacial surgery, pg:-346-355, vol 1, 2013

DISINFECTION: Destruction of pathogenic and other kinds of microorganisms by physical or chemical means. Disinfection is less lethal than sterilization, because it destroys the majority of recognized pathogenic microorganisms, but not necessarily all microbial forms (e.g., bacterial spores).

Disinfection is a process of removing or killing most, but not all, viable organisms.(MIMS-PLAYFAIR).

Disinfection refers to the destruction of pathogenic organisms.(Ronald B Luftig).



DEFINITIONS

DISINFECTANT: A chemical agent used on inanimate objects to destroy virtually all recognized pathogenic microorganisms, but not necessarily all microbial forms

(e.g., bacterial endospores). DECONTAMINATION: Is the process of removal of contaminating pathogenic microorganisms from the articles by a process of sterilization or disinfection. It is the use of physical or chemical means to remove, inactivate, or destroy living organisms on a surface so that the organisms are no longer infectious.

ASEPSIS: Is the employment of techniques (such as usage of gloves, air filters, uv rays etc) to achieve microbe-free environment



DEFINITIONS

Antisepsis is the use of chemicals (antiseptics) to make skin or mucus membranes devoid of pathogenic microorganisms.

Bacteriostasis is a condition where the multiplication of the bacteria is inhibited without killing them.

Bactericidal is that chemical that can kill or inactivate bacteria. Such chemicals may be called variously depending on the spectrum of activity, such as bactericidal, virucidal, fungicidal, microbicidal, sporicidal, tuberculocidal or germicidal.



DEFINITIONS

TRANSMISSION OF INFECTION Infection transmission during dental

procedures is dependent on four factors:1. Source of infection – may be a patient or a

member of the dental team who is suffering from, or is a carrier of an infectious disease.

SOURCE

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Patients suffering from acute infection

Patients in prodromal stage

carriers

known unknown

Ref ; C.P.Baveja, text book of microbiology, 2nd edition, pg:-49-50, 2006Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-33-35 , 3rd edition, 2005


2. Means of transmission – Micro organisms capable of causing disease are present in human blood and saliva. Contact with blood or saliva may transmit such pathogenic organisms causing infection.

3. Route of transmission – Transmission may occur due to inhalation or inoculation.

4. Susceptible host – Is a person who lacks effective resistance to a particular micro organism. E.g immuno compromised patients, pregnant women and children.

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Ref ; C.P.Baveja, text book of microbiology, 2nd edition, pg:-49-50, 2006Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-33-35 , 3rd edition, 2005 05/02/2023 RT/5/INFECTION CONTROLL IN OMFS/72

NOSOCOMIAL INFECTIONS

Hospital acquired infections

Study on efficacy of NI control projected by US CDC in 1970 to reduce NI

and it results approx. 32% reduction in NI in hospitals and health care units.


STRATEGY TO ACHIEVE INFECTION CONTROLScreening

PPE

Aseptic techniques

Sterilization & disinfection

disposal

Laboratory asepsis05/02/2023 RT/5/INFECTION CONTROLL IN OMFS/72 19

PERSONAL BARRIER PROTECTION

Personal protective equipment (PPE), or barrier precautions, are a major component of Standard precautions.

PPE is essential to protect the skin and the mucous membranes of personnel from exposure to infectious or potentially infectious materials.

The various barriers are gloves, masks, protective eye wear, surgical head cap, foot wear & overgarments

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GLOVES All clinical personnel must wear treatment

gloves during all procedures. Types:1. Latex gloves2. Vinyl gloves3. Nitile gloves4. General purpose utility gloves

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Ref ; Daniel M. Laskin, oral and maxillofacial surgery, pg:-346-355, vol 1, 2013Ref : Chitra Chakravathy, textbook of oral & maxillofacial surgery, pg:-12-13 ,2nd edition,201105/02/2023 RT/5/INFECTION CONTROLL IN OMFS/72

PROTECTIVE GOWNS

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Gown type Situation and RationaleCotton/linen, reusable or disposable,

long-sleeved isolation gownsUse if contamination of uniform or

clothing is likely or anticipated

Fluid resistant isolation gown or plastic apron over isolation gown

Use if contamination of uniform or clothing from significant volumes of

blood or body fluids is likely or anticipated (fluids may wick through

non-fluid resistant reusable or disposable isolation gowns)

impervious gowns e.g., Gortex® Fluid

Use if extended contact or large volume exposure (e.g., large volume blood loss during resuscitation of MVA victim or

surgical assist)

Ref ; Daniel M. Laskin, oral and maxillofacial surgery, pg:-346-355, vol 1, 2013Ref : Chitra Chakravathy, textbook of oral & maxillofacial surgery, pg:-12-13 ,2nd edition,201105/02/2023 RT/5/INFECTION CONTROLL IN OMFS/72

PRECAUTIONS TO AVOID INJURY EXPOSURE

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Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-24-26, 3rd edition, 2005Ref ; Daniel M. Laskin, oral and maxillofacial surgery, pg:-346-355, vol 1, 2013


EMERGENCY & EXPOSURE INCIDENT PLAN

Management of exposure includes:A. General wound care and cleaning.B. Counseling of the exposed worker regarding blood

borne pathogens.C. Source patient testing for HBV,HCV and HIV

(consent required).D. Documentation of the incident and review.E. Post exposure assessment and prophylaxis for the

health care worker.F. Baseline and follow up serology of the worker.

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Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-24-26, 3rd edition, 2005Ref ; Daniel M. Laskin, oral and maxillofacial surgery, pg:-346-355, vol 1, 2013Ref : Neelima malik, textbook of oral & maxillofacial surgery, pg:-70-101 ,2nd edition,2011


HAND CLEANSERS

CHLORHEXIDINE BASED – these contain 2- 4% chlorhexidine gluconate with 4% isopropyl alcohol in a detergent solution with a pH of 5.0 to 6.5. They have broader activity for special cleansing(e.g: for surgery, glove leaks, or when clinician experiences injury). But it can be hazardous to eyes.

POVIDONE IODONE – contain 7.5-10% povidone iodine, used as a surgical hand scrub.

PARACHLOROMETEXYLENOL(PCMX) – these are bactericidal and fungicidal with 2% concentration. Non irritating and recommended for routine use.

ALCOHOL HAND RUBS- ethyl alcohol and isopropyl alcohol are widely used at 70% concentration. They are rapidly germicidal when applied to the skin.

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Ref : C.P BAVEJA, Text book of microbiology, pg:-20-22,2nd edition, 2006Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-4-6, 3rd edition, 2005Ref ; Daniel M. Laskin, oral and maxillofacial surgery, pg:-346-355, vol 1, 2013Ref : Chitra Chakravathy, textbook of oral & maxillofacial surgery, pg:-12-13 ,2nd edition,201105/02/2023 RT/5/INFECTION CONTROLL IN OMFS/72



LEVEL SPECTRUM USE EXAMPLES

Low level Bacteria exceptmycobacteria not spores.Some fungi and someViruses.

Surfaces withoutblood

Quaternary ammoniums, some phenolics,some iodofors

Intermediatelevel

Mycobacteria, not spores.Most fungi and most viruses.

Surfaces withblood

Quaternary ammoniums with alcohol, chlorines, phenolics, iodofors

High level All microbes except spores

Immersion Glutaraldehyde, strong peroxides, ophthaldehyde

CHEMICALS FOR DISINFECTION

Ref: Cohen: Pathways of the Pulp, 9th Edition pg:-1-9,2007

INSTRUMENT PROCESSING



Selection of packaging materials for sterilizationSteam sterilization cellulose, cotton/polyester cloths, window

packs, perforated rigid containers with bacterial filters, glass containers for liquids

Dry heat (hot air oven) Metal canisters and tubes of aluminium foil, glass tubes, bottles

ETO Paper & Plastic, perforated rigid containers with bacterial filters

Low temperature steam Paper, cloth

Radiation sterilization Polyethylene, PVC, polypropylene, foil.



ULTRASONIC CLEANERS AND SOLUTIONS

Ultrasonic cleaning is the safest and most efficient way to clean sharp instruments.

An ultrasonic cleaning device should provide fast and thorough cleaning without damage to instruments; have a lid, well-designed basket, and audible timer; and be engineered to prevent electronic interference with other electronic equipment


Physical agents:1. Sunlight2. Drying3. Dryheat: flaming,

incineration, hot air 4. Moist heat:

pasteurization, boiling, steam under pressure, steam under normal pressure.

5. Filtration: candles asbestos pads, membranes

6. Radiation7. Ultrasonic and sonic

vibrations

Chemical agents:1. Alcohols: ethyl, isopropyl,

trichlorobutanol2. Aldehydes:

formaldehyde, glutaraldehyde

3. Dyes4. Halogens5. Phenols 6. Surface-active agents7. Metallic salts8. Gases: ethylene oxide,

formaldehyde, beta propiolactone.


Agents used in sterilization

The four accepted methods of sterilization are :A. Steam pressure sterilization (autoclave) B. Chemical vapor pressure sterilization-

(chemiclave)C. Dry heat sterilization (dryclave) D. Ethylene oxide sterilization


Ref : C.P BAVEJA, Text book of microbiology, pg:-20-30,2nd edition, 2006Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-24-26, 3rd edition, 2005

STEAM PRESSURE STERILIZATION (AUTOCLAVING)


Advantages of Autoclaves. Autoclaving is the most rapid and effective method for sterilizing cloth surgical packs and towel packs.

Is dependable and economicalSterilization is verifiable.



Disadvantages of Autoclaves. Items sensitive to the elevated temperature cannot be autoclaved.

Autoclaving tends to rust carbon steel instruments and burs.

Instruments must be air dried at completion of cycle.



CHEMICAL VAPOR PRESSURE STERILIZATION (chemiclaving)


Advantages1. Carbon steel and

other corrosion-sensitive instruments are said to be sterilized without rust.

2. Relatively quick turnaround time for instruments.

3. Load comes out dry.

4. Sterilization is verifiable.

Disadvantages1. Items sensitive

to the elevated temperature will be damaged. Vapor odor is offensive, requires aeration.

2. Heavy cloth wrappings of surgical instruments may not be penetrated to provide sterilization.



DRY HEAT STERILIZATION

Conventional Dry Heat Ovens Short-Cycle, High-Temperature Dry Heat Ovens


Advantages1. Carbon steel

instruments and burs do not rust, corrode, if they are well dried before processing.

2. Industrial forced-draft hot air ovens usually provide a larger capacity at a reasonable price.

3. Rapid cycles are possible at high temperatures.

4. Low initial cost and sterilization is verifiable.

Disadvantages1. High temperatures

may damage more heat-sensitive items, such as- rubber or plastic goods.

2. Sterilization cycles are prolonged at the lower temperatures.

3. Must be calibrated and monitored


Ref : C.P BAVEJA, Text book of microbiology, pg:-20-27,2nd edition, 2006Ref : Chrish H.Miller, Charles John Palenik, infection control, pg;-29-35, 3 rd edition, 2005


METHOD TEMPERATURE(ºc) HOLDING TIME(MINS)

AUTOCLAVE 121 15

126 10

134 3

HOT AIR OVEN 160 45

170 18

180 7.5

190 1.5

ETHYLENE OXIDE STERILIZATION (ETO)


MOBILE FUMIGATOR

Advantages:1. Operates

effectively at low temperatures

2. Gas is extremely penetrative

3. Can be used for sensitive equipment like handpieces.

4. Sterilization is verifiable

Disadvantages:1. Potentially

mutagenic and carcinogenic.

2. Requires aeration chamber ,cycle time lasts hours

3. Usually only hospital based.



OTHER STERILIZATION METHODS

Gamma radiationDry-Heat Sterilizers

Liquid Chemicals Performic Acid Filtration Microwave U.V radiationFlash sterilization

Glass Bead “Sterilizer”

Vaporized Hydrogen Peroxide

Formaldehyde Steam Gaseous Chlorine Dioxide

Vaporized Peracetic Acid

Infrared radiationOxygen plasma sterilization


Ref : C.P BAVEJA, Text book of microbiology, pg:-20-27,2nd edition, 2006Ref: Cohen: Pathways of the Pulp, 9th Edition pg:-1-9,2007

Ozone sterilization is the newest low-temperature sterilization method recently introduced in the US and is suitable for many heat sensitive and moisture sensitive or moisture stable medical devices

Ozone sterilization is compatible with stainless steel instruments.

Ozone Parameters • The cycle time is approximately 4.5 hours, at a temperature of 850F – 940F.



ozone

Various new methods of sterilization are under investigation and development.

1. Peroxide vapor sterilization - an aqueous hydrogen peroxide solution boils in a heated vaporizer and then flows as a vapor into a sterilization chamber containing a load of instruments at low pressure and low temperature

2. Ultraviolet light - exposes the contaminants with a lethal dose of energy in the form of light. The UV light will alter the DNA of the pathogens. Not effective against RNA viruses like HIV.

Product made with antimicrobial copper alloy (brases & bronzes) destrots a wide range of organism in a short period of time. US environment protection agency has approved this.


NEW METHODS OF STERILIZATION

Ref : C.P BAVEJA, Text book of microbiology, pg:-20-27,2nd edition, 2006Ref: Cohen: Pathways of the Pulp, 9th Edition pg:-1-9,2007

NEWER TECHNIQUES

Electrospun Poly(lactic acid) (PLA) Fiber Alignment for Biomedical Applications

New disinfection methods include a persistent antimicrobial coating that can be applied to inanimate and animate objects (Surfacine), a high-level disinfectant with reduced exposure time (orthophthalaldehyde), and an antimicrobial agent that can be applied to animate and inanimate objects (superoxidized water).

New sterilization methods include a chemical sterilization process for endoscopes that integrates cleaning (Endoclens), a rapid (4-hour) readout biological indicator for ethylene oxide sterilization (Attest), and a hydrogen peroxide plasma sterilizer that has a shorter cycle time and improved efficacy



HANDPIECE SURFACE CONTAMINATION CONTROL


Ref : Cross infection control, journal of dental nursing, pg:-392-397, vol 9, no.7, july 2013

Surgical hand piece sterilization


Should DoRemove bur and disconnect handpiece from chair.

Wipe handpiece with alcohol.Locate appropriate hole and spray lube for 2-3 seconds.

Attach handpiece to swivel unit and insert bur.

Run handpiece for 30 seconds to eliminate lube.

Wipe handpiece with alcohol.05/02/2023 RT/5/INFECTION CONTROLL IN OMFS/72 50

Should DoInsert in autoclave bag…….paper on at least one side of bag.

Load in autoclave with cellophane side down.

Remove from autoclave immediately after all cycles are complete.

Always allow cooling to room temperature, paper side up.

Do not force cool with water or other means.


Should not doDo not immerse hand piece in any solvent, cleaner or ultrasonic solution.

Do not clean hand piece in ultrasonic cleaners or dry heat sterilizers.

Do not exceed temperature of 135°C.Do not use chemical disinfectants, when combined with heat of the autoclave, disinfectants may significantly reduce hand piece life

Do not use all cellophane bags05/02/2023 RT/5/INFECTION CONTROLL IN OMFS/72 52

Important points to remember

1) The patient is the center of the sterile field.

2) Keep hands at waist level and in sight at all times.

3) Keep hands away from the face.

4) Never fold hands under arms.

5) Gowns are considered sterile in front from chest to level of sterile field, and the sleeves from above the elbow to cuffs. Gloves are sterile.

6) Sit only if sitting for entire procedure.



THE THEATRE


National Accreditation Board for Hospitals and Healthcare Providers

OT Size: Standard OT size of 20’ x 20’ x 10’ Occupancy: Standard occupancy of 5-8 persons at any given point Non adherent ,nonporous surfaces- OT WALL CLADINGS Rounded corners


AIR QUALITY

Air Filtration: The air quality at the supply i.e. at grille level should be Class 1000

Class 1000 means a cubic foot of air must have no more than 1000 particles


PREPARATION OF

SURGERY


Principles Of Aseptic Technique

1. Only sterile items are used within the sterile field 2. Sterile persons are gowned and gloved 3. Tables are sterile only at table level 4. Sterile persons touch only sterile items or areas 5. Unsterile persons avoid reaching over the sterile field 6. The edges of anything that encloses sterile contents are considered

unsterile 7.The sterile field is created as close as possible to the time of use 8. Sterile areas are continuously kept in view 9. Sterile persons keep well within the sterile area 10. Break of the integrity of microbial barriers results in contamination


Preoperative showering with hexachlorophene has shown reduction in wound infection.

Short preoperative hospital stay reduces pathogenic bacteria on skin and nasal carrier state.


Pre-operative hair removal Shaving a patient’s skin before surgery may

raise the risk of an infection. In its guidelines for preventing surgical site

infections, the Centre for Disease Control recommends that hair should not be removed unless it will interfere with the operation.

When shaving is necessary, electrical clippers should be used.

Preferably immediately before surgery Shaving with a razor blade causes microscopic

nicks in the skin that can become bacterial breeding grounds.


Before the skin preparation of a patient is initiated, the skin should be free of gross contamination (i.e., dirt, soil, or any other debris)

The patient’s skin is prepared by applying an antiseptic in concentric circles, beginning in the area of the proposed incision and medial to lateral.

The prepared area should be large enough to extend the incision or create new incisions or drain sites

Patient skin preparation


DRAPING THE PATIENT

Turban draping

Commercially available drapes



Wet your hands, apply a little soap or forearms to 5cm above your elbows for one complete minute


Gowning


Gloving


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Hazardous Waste management

Hazardous waste products include:Blood and blood productsBody fluids and tissueCultures VaccinesSharpsGlovesSpeculaInoculating loopsPaper product contaminated with body fluids


CLINICAL WASTE DISPOSAL


YELLOW BAG RED BAG BLUE BAG BLACK BAG ORANGE BAG

•Human anatomical waste•Animal waste•Microbiology and biotechnology waste•Solid waste( items contaminated with body fluids)

•Microbiology and biotechnology waste•Solid waste (tubings, iv catheters)

•Waste sharps•Solid waste (tubings, iv catheters)

•Discarded medicines and cytotoxic drugs•Incineration ash•Chemicals used in disinfection & insecticides

• Animal and slaughter house waste

Ref. Guidelines on HIV testing, National AIDS Control Organization (NACO), march 2007, pg :-32 Ref. Preventive and social medicine, K.PARK, pg.738-739, 22nd edition, 2013

CONCLUSION & REFERENCES

“Strictly following the protocols of sterilization & disinfection will results in high success rate and decrease in surgical infections & postoperative complications ”


1. Anantnarayan-Textbook of Microbiology

2. LJ Peterson-Cotemporary Oral & Maxillofacial Surgery

3. Laskin-Textbook of Oral & Maxillofacial Surgery

4. Fonseca-vol-2, edition 3

“There Is No Compromise with SterilityIt’s either Sterile or Unsterile.”

Take home message…….


Health & Medicine

5. infection control in omfs(71) Dr. RAHUL TIWARI