By Katherine Ferguson, DMDWe all care for our patients and when we are the patients, we want our health-care providers to care for us too. One of the best things you can do for your patients, yourself, and significant others is to practice stellar infection control. One of the worst things is to practice sub-par infection control. We are all quite polished in our delivery of education to patients, and to the intricate, long list of tasks that every surgery we perform demands, but none of that matters if we put the patient at risk for cross-contamination. Cross-contamination has the potential of causing a postsurgical infection that delays healing or that causes the surgery to fail, or worse. It can be a life-changing event for everyone involved.If health-care providers are responsible for cross-contaminating a surgical site and we fail, the patient may have an infection that is easy to treat and the surgery may be performed again at a later date. If that is all that happened — everyone got lucky that time. If, however, the worst happens, the patient can leave your office with an infection that can be the eventual cause of his or her death. If you have contaminated yourself, you may have an infection that can be easily treated. If the worst happens, you can leave the office that day with an infection that will be the cause of your death and, potentially, the sickness and death of your loved ones to whom you unintentionally spread the disease.Microbes can be spread in a variety of ways. One way is via fomites. A fomite is an inanimate object that serves to transfer infection organisms from one individual to another. An example would be a clinic counter top. Microbes can be splashed onto a counter top. If no one disinfects the counter top and someone comes along and puts his or her hand on the same counter top, that person now has the microbe on his or her hand. The person then wipes his or her eye or nose. He or she has just transferred the microbe from its original host person to him or herself.Microbes can also be spread via the air we breathe. When a gas is formed with either solid or liquid particles suspended in them, we call it an aerosol. We breathe aerosols into our lungs if we are not wearing proper protection such as a facemask. Infectious microbes can be transferred in this fashion from one person to another. When a handpiece produces water spray and contacts the patient’s saliva or blood, it causes an aerosol full of whatever is in the saliva or blood. This aerosol is sometimes invisible to our eyes, but we breathe it in nonetheless. Whenever aerosols are produced, it is important to protect yourself with a facemask. It is also important to change your mask once it has become wet on the outside from a large amount of aerosol and also wet on the inside at the same time from the moisture of your own breath. Once both sides of the mask are wet, it acts as a wick. When you breathe, you can actually pull some of the finer particles through the mask now that it is wet through and through; you are not as protected as you may think.Before a patient is seated, you yourself should be comfortable being the next patient in that room for treatment. All surfaces that may have been contaminated by the last procedure should be disinfected. If you are not ready to be treated as a patient in that room, then the room is not ready.It is recommended that patients have eye protection for procedures for which it is reasonable to expect there will be splash or splatter or other means of eye contamination. This includes simple procedures as well as complex ones. A quick, simple procedure is no longer quick when you have to take your patient to the eyewash station and wait while he or she flushes for 15 minutes. A long procedure that has to be interrupted at an inopportune time becomes even longer.Eye protection has to be worn whenever splash, splatter, or aerosol is expected. Occasionally, your eyes or your patients’ eyes will be splashed with a chemical or biologic material. You need to know where the eyewash station is in your office. If your eyes or your patient’s eyes become contaminated, go directly to the eyewash station and wash for 15 minutes (Fig. 1).
Fig. 1I always recommend that over garments be worn whenever treating patients, as well as for instrument scrubs. I also recommend that eye protection and masks be worn at the same time. My favorite for eye protection is the face shield. It offers superior eye protection as well as protection to the rest of the face that eyewear and masks alone cannot. A face shield is not a substitute for a mask. The face shield does not protect your lungs against aerosol as a mask does. A mask must be worn as part of your personal protective equipment even with a face shield (Figs. 2 and 3).
Fig. 2
Fig. 3You have a lot to keep in mind during a procedure, including trying to help your doctor at the same time as you are helping the patient. You also need to keep in mind infection control during procedures. If your gloves or your doctor’s gloves appear to have a perforation, advise the doctor as the procedure will need to be immediately paused while the gloves in question are removed, a proper hand washing takes place, and a new set of gloves is donned. Your doctor should do the same for you. If your doctor sees that any personal protective barriers may be compromised, the procedure needs to be paused so that the situation can be corrected.If a scalpel, needle, suture, scaler, or similarly sharp instrument is being used, do not keep your fingers adjacent to it. When you need to retract, use your instruments to do that, such as your mirror, tongue depressor, or Minnesota retractor. If someone slips or the patient moves unexpectedly, it’s better to have the sharp instrument come in contact with your retractor than with your finger. It is a must that you follow the manufacturer’s directions for the disinfectant you use in the operatories. Many manufacturers have minimum times that their product needs to be in contact with a surface before being removed/wiped down for the product to disinfect properly. Many manufacturers recommend the disinfectant be sprayed, then wiped, and then sprayed again before a final wipe. This decreases the bioburden for the final spray to disinfect.All sharps should be discarded in the operatories as close to the point at which they were used as feasible. Each treatment room should have its own sharps container to accomplish this. This decreases the transport of sharps from one part of the office to another and so decreases the potential for accidents. Transportation of instruments from the treatment room to the sterilization area should be accomplished by using a puncture-resistant container with a secured top. This decreases the chance of someone accidently bumping into someone else and spilling the contaminated instruments on them (Figs. 4 and 5).
Fig. 4
Fig. 5When you are in the sterilization area and ready to clean the instruments before sterilization, keep in mind your own protection as well as the task at hand of removing the bioburdon before running the instruments in the autoclave. You should be wearing heavy-duty, puncture-resistant gloves for instrument scrubs. You should be placing the instruments in an ultrasonic cleaner before scrubbing them, and scrubbing only when necessary. Use a scrub brush with a handle to keep your hands as far away from the sharp part of the instrument as possible. You should be wearing all of your protective equipment. It’s easy to get a splash in the sterilization room, and you want to be covered (Fig. 6).
Fig. 6Hand washing with liquid soap is best. (A proper hand wash is to be preformed for 15 seconds — about the same time it takes you to sing the “Happy Birthday to You” song in your head.) There have been pathogenic organisms found on and around bar soaps both during and after use. When the liquid soap in the liquid soap container is low, do not simply “top it off” with a refill to the existing remaining soap. Either discard the entire container or wash the container and let it dry thoroughly before refilling. The chemicals used in the liquid soaps for preservatives that keep the soaps themselves from being contaminated have a limited shelf life and will go bad with time, causing the liquid soap to become contaminated. If that occurs, when you’re “soaping” your hands, you’re doing the equivalent of dipping them into liquid bacteria without being aware of this. Waterless hand sanitizers are great when there is no water available with which to disinfect. They are quite effective against viruses and also against bacteria. However, they are only as effective as they are able to contact the microbes. If there is visible soil or other organic debris present, they will not be as effective as you expect them to be. In the majority of situations, hand washing with warm, soapy water is still the most effective way to clean your hands. If you want to use alcohol rubs, the best combination would be to wash with warm, soapy water for at least 15 seconds, dry thoroughly, and then apply the alcohol rub. The water wash will remove the organic material and any residual powder or residue from your gloves and allow the alcohol to perform to its fullest.We all wash our hands several times during a treatment day. The proper protocol is to have a morning scrub of two minutes before treating patients. This is the first hand wash for the day. Then hands should be washed before and after wearing gloves, as well as after using the restroom and before and after eating. Most of us remember to wash hands before gloving. We normally make it a point to do this in front of the patient. This also benefits the operator, because any pathogens that may be on the skin are either completely removed or are decreased in significant numbers before the gloves go on. It is important to wash for the recommended time of at least 15 seconds in warm, but not hot, water. Hot water, although it feels wonderful, may be damaging your skin and you will not necessarily know it. It is also important that if you choose to wear rings that will be under the gloves, that the skin under the rings is dried as thoroughly as the rest of your hands before donning gloves. Once the gloves go on, we create an incubation hothouse for any remaining microbes. If there’s anything that microbes love, it’s a warm, moist area in which to reproduce. While it occurs to most to wash hands before gloving, it may not make immediate sense to have to wash your hands after wearing gloves. The rationale for this is that if you had any perforation that you were unaware of as well as to remove any residual glove contaminants that remain on the skin after degloving, including the powders and latex allergens that may remain on the skin.After washing our hands repeatedly during the day, they may be irritated and begin to have surface cracks in the skin. We want to avoid this as much as possible. Healthy, unbroken skin is our primary defense against pathogens. To help prevent skin dryness and the skin cracking associated with it, lotions are recommended, but only lotions that have no petroleum products in them. Petroleum-based lotions can weaken latex gloves and increase permeability. We have standard of care infection control that must be practiced by all involved in patient care. Our patients have entrusted their health to us, and that is not a responsibility anyone should take lightly.Infection control is a never-ending job. Keeping yourself current on infection-control protocol is an ongoing process that will last your whole career. If you learn of something that will keep others better protected, share that information. We are all in this together. Let’s all keep each other safe (Figs. 7 and 8).
Fig. 7
Fig. 8DefinitionsMicrobe / microorganism—any organism that is too small to be visible to the naked eye. Example: bacteria, viruses, fungi, mycoplasmas, protozoa, rickettsiae.Bioburden — the organic material left on a surface to be decontaminated.Pathogen — a microorganism that produces disease.Normal fauna — the normal microbes found on a surface. Example: the normal bacteria found on the surface of the skin.Opportunistic pathogen — an organism that rarely produces disease in healthy individuals.To don gloves — to put on gloves.Petroleum — a natural, flammable liquid hydrocarbon mixture found principally beneath the surface of the Earth that is processed for fractions including gasoline, kerosene, fuel, asphalt, paraffin wax, and natural gas.Organic material — material derived from living organisms.ReferencesCenters for Disease Control and Prevention www.cdc.gov. Jan. 2010; “Hand Hygiene.”Guidelines for hand hygiene in health care settings: Recommendations of the Health Care Infection Control Practices Advisory Committee and the HICIAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly 2002;51 (No.RR-16).Guidelines for Infection Control in Dental Health-Care Settings, 2003. Morbidity and Mortality Weekly, Dec.19, 2003; 52(RR-17):1-61.Kabara JJ, Brady MB. Contamination of bar soaps under “in-use” conditions. Journal of Environmental Pathology, Toxicology and Oncology. 1984; 5:1-14.Larson EL. Association for Professionals in Infection Control and Epidemiology Guidelines Committee. American Journal of Infection Control.1995; 23:25251-269.Larson EL, Norton Hughes CA, Pyrak JD, Sparks SM, Cagatay EU, Bartkus JM. Changes in bacterial flora associated with skin damage on hands of health care personnel. American Journal of Infection Control 1998; 26:513-521.United States Department of Labor, Occupational Safety and Health Administration Enforcement procedures for the occupational exposure to blood borne pathogens. Washington, DC: U.S. Department of Labor, Occupational Safety and Health Administration, 2001, Directive Number. CPL 02-02-069. Accessed Sept 2009.
