Infection control – ortho clinic

Infection control & clinic rules

Introduction
The use of rules and regulations to help prevent the spread of
infection is by no means a new concept in healthcare. A clinic rule is
defined by the General Dental Council as one of broad application,
representing a standard of behavior, to which the dental practitioner
should aspire and will publicize to patients and/or healthcare
professionals. Infection control has special significance in preventing
the spread of infectious diseases.
According to studies, Orthodontists have the second highest incidence
of hepatitis B Among dental profession. Puncturing of the skin with
contaminated instruments, sharp edges of orthodontic appliance
represent the greatest danger for orthodontists and staff as any cuts or
abrasions will allow micro-organisms to enter the body.
Diseases such as hepatitis-B, HIV and tuberculosis have long
incubation period. hence, it is difficult to identify the source of such
infections to the dental practitioners and patients. Dentists and dental
staff have an increased risk of being infected with airborne pathogens
such as COVID-19 because they are always exposed to droplets and
aerosols produced during specific treatment procedures. Transmission
may occur due to the inhalation of droplet and aerosols from infected
individual or by direct contact with mucous membrane, oral fluids and
contaminated instruments or surfaces.

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Importance of Infection Control in Dentistry

1. lowering the risk of cross contamination (between patient and
staff) by reducing the levels of pathogens.
2. Break the cycle of infection.
3. Use universal precautions with every patient.
4. Protect patients and personnel from occupational infections.

Means of transmission

The role of clinic rules in preventing the infection

The most effective way to prevent the spread of infectious diseases is
to assume that every person is potentially infectious and to use the
appropriate barriers and/or infection control measures with every
patient. Clean barriers or surfaces can become contaminated during
patient care and should be protected with the use of disposable
materials. When the protective barrier is removed between patients, the
surface is clean and dry, and a new barrier can be applied.

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Infection control related terms

•Disinfection: Destruction or deactivation of microbial life except
spores by chemical means mainly on inanimate surfaces.
•Sterilization: Destruction or removal of all microbial life
including spores by physical or chemical means.
•Microbial life: microorganisms include viruses-fungi-bacteria-
spores.
•Immunization: The process or procedure by which a subject is
rendered immune, or resistant to a specific disease. This term is
often used interchangeably with vaccination or inoculation,
although the act of inoculation/vaccination does not always result
in immunity.

Types of disinfection
Types of disinfection depends on the amount and kind of the
microorganisms that been targeted:
1. High-level disinfection: for destruction of viruses,
vegetative bacteria, fungi, mycobacteria and some not all bacterial
spores.
2. Intermediate-level disinfection: for destruction of vegetative
bacteria and mycobacteria not efficient in destruction of non-lipid
viruses and fungal spores.
3. Low-level disinfection: for destruction of some vegetative
bacteria, viruses, and fungi.
Disinfectants can be solutions (for floor, surfaces, and instruments
soaking) Or spray (for air and surfaces).
Efficacy of disinfectants depends on:
• Temperature.

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• PH.
• Concentration of germicide.
• Exposure time of germicide.
• Dryness to prevent dilution.
Disinfectants commonly used in dentistry:
• Alcohol.
• Phenols.
• peroxygen compounds.
• quats (quaternary ammonium).
• Recently, UV light is used as disinfectant as it alters the
biological components of micro-organisms by breaking the
chemical bonds in DNA/ RNA proteins.

Types of sterilization
I. Chemical sterilization

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II. Physical sterilization

The most used methods of sterilization in dentistry:

I. Hot air Over (Dry-Heat):

• It breaks / denatures protein of micro- organisms.
• Cycle is under 160°c for 1-2 hour.
• No liquids and No plastics.
II. Rapid-Heat Sterilizer
• It Keeps internal air flow.
• Cycle is under 375°F
6° min→ unwrapped Instruments.
12 min →wrapped Instruments.

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• No liquids and No plastics.

III. chemical vapor

• Using solution (acetone, Ketone, water, alcohol ,23%
formaldehyde, and 73% ethanol). It isn’t toxic but has bad odor,
so it needs room with good ventilation.
• Suitable For orthodontic Instruments.
• Cycle under 25-pound pressure ,132°C for 20 min.
IV. Ethylene -Oxide
• Gas, with high Penetration ability, acts on DNA/RNA protein.
• Disadvantages: 4h / cost/ coat Formation if there is
moisture/needing 24 hours for dissipation of gas.
V. Autoclave (Moist heat)
• It denatures and coagulates protein of microorganisms.
• Cycle is under 15-pound pressure and 121 °C for 20 min.
• No plastic and non-stainless-steel instruments may corrode.

Disinfectant Antiseptic

Both are biocides contain wide variety of active chemical agents.

Can be sporostatic but not -Static or -cidal for
necessarily sporicidal. microorganisms.
For inanimate surfaces. In/on living tissues.

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Biocides can be either static or cidal.

Chemical agents destroy/kill the microorganisms

ex: antibiotics.
Chemical agents Inhibit growth of microorganisms ex:
handwashes.

Infectious Diseases in Dental Clinic

There are 5 types of micro-organisms:
1. Virus.
2. Bacteria
3. Fungus
4. Parasite
5. Protozoa
The spread of any micro-organism depends on its pathogenic capability.
Factors that affect the pathogenic capability of micro-organisms are

- Virulence: Which is the ability of the micro-organism to cause

damage to its host.

- Host resistance: Which is the ability of the host to arrest the

growth or development of the pathogen.

- Concentration: Which is the number of micro-organisms.

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Viral infections
There are 5 types of viral infections:
I.Hepatitis B is the most important type, WHO estimates that it
causes more than a million deaths per year worldwide, it’s an
enveloped DNA virus that infects and multiplies in the human liver
cells, consisting of 3 components, 1 surface antigen and 2 inside
the virus itself, its sporadic in highly populated areas. Its Mode of
transmission is through infected body fluids.
Only 1\3 of the patients exhibit the easily recognizable symptoms
which are:
a) Yellow skin and whites of the eye
b) Dark urine
c) Rash and itching
The dental team is at a high risk of infection, almost 10,000 to
12,000 gets infected per year. The best cure for this disease is
prevention by vaccination.
Hepatitis B vaccination is at 0,1 &6 months. Route: IM in the
deltoid region. Vaccine effectiveness: less than 90% after 3rd dose.
The effectiveness of the dose is determined by the Anti-HBsAg
titers, it should be more than 10 mIU/ml after 1-2 months of the 3rd
dose. If it is less than 10 mIU/ml, 3 3-dose revaccination schedule
is followed. Non-responders are those who fail to achieve more
than 10 mIU/ml titers even after the revaccination schedule.
II.Hepatitis types A & E are of no concern to the dental team as their
only route of transmission is fecal-oral.

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III.Hepatitis type C is a blood-borne virus that can be transmitted to

the dental team through infected needles.
IV.Hepatitis type D is regarded as a complication of hepatitis B virus.
V.AIDS (acquired immunodeficiency syndrome) is caused by
replication of the HIV-1 in the T4 lymphocytes which weakens the
immune system. AIDS is transmitted through:
a) Prenatal contact
b) Sexual contact
c) Exposure to infected blood
Transmission through saliva is rare as the count of the micro-
organisms in the saliva is very low.
VI. Herpes simplex virus, there are 4 types:
• Herpes simplex type 1
• Herpes conjunctivitis (in the conjunctiva of the eye)
• Herpetic cold sores (mainly as cold sores at the commissures)
• Herpes simplex type 2
Herpes simplex type I is the most common infectious herpes
simplex virus that is of greater incidence among adults.
Transmission is through direct contact. It is usually accompanied
by fever, malaise, cervical lymphadenopathy, and ulcerative
gingivomatitis. It usually starts with discomfort in the site of
infection and the appearance of clusters of small vesicles that then
rupture followed by its coalescence into a larger ulcer.

BACTERIAL INFECTIONS

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I.Tuberculosis is a lung infection caused by Mycobacterium

tuberculosis. It requires prolonged exposure to the infectious
disease and as a result it is of very low incidence to the dental team.
The mode of transmission is through droplets.
II.Syphilis still occurs in the developing countries even with the
presence of penicillin. Lesions of secondary syphilis are highly
infectious.

FUNGAL INFECTION
Oral candidiasis is caused by candida albicans which is normally
found as normal flora in the oral cavity, but when the immunity of the
person is compromised, it attacks its host and produces clinical
symptoms. It’s a thick curdy white coating on the surface of the tongue
that is associated with atrophic burning sensation and itching. It is said
theoretically that its mode of transmission is through droplets.

PARASITIC INFECTION
Pneumocystis Pneumonia ‘s causative organism is Pneumocystis
jirovecii.
Its Risk factors are:

•Immunosuppressed patients

•After solid organ transplantation

•Inflammatory or autoimmune disease

•Blood cancer

•Malnourished children
Its Clinical symptoms:

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•Fever

•Cough

•Difficulty in breathing

•Chest pain

•Chill & tiredness

Areas of infection control

Orthodontist and staff
1. Good personnel hygiene is the keystone of protection.
2. Careful hand washing, at least for a minute in cold water,
with germicidal soap.
3. Using hand disinfectant after all preparations.
4. Proper gloves should be used.
5. Complete medical history should be taken from the
patient by the orthodontist to determine who are more
likely to carry pathogenic organism.
Instruments
1. Orthodontist must decide for himself, which instruments need
to be sterilized.
2. Instruments can be categorized according to Spaulding
system:
a. Critical:
Instruments that penetrate the mucosa must be sterilized ex:
Bands, band removers, ligatures directors, band forming
pliers etc.

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b. Semi Critical:
Instruments that touches the mucosa should be sterilized
whenever possible or treated with high level disinfectants ex:
most of the orthodontic instruments, mirrors retractors, dental
hand pieces.
c. Least Critical:
Instruments that don’t touch mucous membrane ex: distal-end
cutter, ligature cutter, arch forming pliers, torquing keys,
bracket positioning gauges, V-bend forming plier etc. should
be disinfected.
Operator site
1. Dental chair, table, light handles, spittoon, three-way syringes
etc., should be considered as contaminated areas. It should be
wiped frequently with 70% isopropyl alcohol.
2. It is advisable to have straight tubing for the hand piece, three-
way syringe and hand pieces should be fitted with non-retraction
valve. Minimize the number of tubing and wires which can
accumulate dust.
3. A regular informative medical history of the patient can help to
identify factors that assist in the diagnosis of oral and systemic
disorders. Many patients often fail to give the information.
Every patient should be treated as potentially infectious.
This important fundamental application of infection control is termed
as Universal Precautions. The blood and body fluid precautions
substantially reduce the clinical guess work of a patient’s infection
status.

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Personal protection:
Repeated exposure to saliva and blood during the dental treatment
procedures may challenge the dentist’s immune defense with a wide
range of microbial agents. So, immunological protection and barrier
protection are required.
Immunological Protection
The operator should be vaccinated with available vaccines of
proven efficacy to prevent the onset of clinical or sub-clinical infection.
The occupational risk of catching hepatitis B, measles, rubella,
influenza, and certain other microbial infections can be minimized by
stimulating artificial active immunity.
Barrier Control
Barrier protection is against the range of potential pathogens
encountered during patient treatment. The physical barriers like
disposable gloves, face masks, protective eyewear, headcap and
surgical gowns during treatment procedure will minimize the infectious
exposure.
Certain points which should be kept in mind:
- Gowns must be cleaned daily.
- Short nails will avoid tears in gloves and decrease the chance of
patient discomfort.
- Hand jewelry and watches also should be avoided.
- Hands should be cleaned Pre and post wearing gloves.
- Washing is recommended if the procedure involved more than 15 -
20 minutes.
- For routine OPD patients, use of hand scrub in between patients
is recommended.
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- Gloves should be changed after every patient and should be

changed if torn or visibly soiled while working on one patient.
- Orthodontist’s gloves: The risk of glove puncture is high for
orthodontists, who repeatedly handle wire bands and ligatures,
although puncturing and tearing can be reduced using elastomeric
ligatures .Orthodontist can use puncture resistant gloves which are
thicker at the palm, a high stress area for ligature placement and
thinner material at the fingertips. Improper fitting gloves and reuse
of gloves are not recommended. Washing of gloves with
antiseptics increases the size and number of pinholes.

Special consideration for orthodontic armamentarium

Orthodontic pliers
- High-quality stainless-steel pliers sterilized by steam, dry heat,
chemical vapor, and ethylene oxide gas.
- Plier with plastic part sterilization with ethylene oxide gas.

Orthodontic wires
- TMA wires sterilized with ethylene oxide, autoclaving.
- NiTi wires sterilized with ethylene oxide.
- Stainless steel wires treated with autoclave, dry heat, and ethylene
oxide.

Orthodontic bands
- Preformed bands are first checked on the patient cast, if in case
they don't fit intraorally then these tried bands are cleaned in

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ultrasonic cleaner and disinfected with disinfectant solution for

recommended time as per manufacturer before placing it back in
the box.

Elastomeric Chains and Ligatures

- Chemicals are not suitable for disinfection of elastomeric
ligatures and E-chains because they alter the physical properties of
the elastics.
For E-chains it is best to cut-off some more above that is required
and discard the rest.

Impression trays
- Aluminum tray: heat or gas sterilization.
- Plastic trays: ethylene oxide sterilization or disinfection by
NaOCl or iodophor.

Stone cast disinfection

- disinfection of wax bites by a spray-wipe-spray technique should
remain wet after the second spray for at least 10 mins.

Disinfection of removable appliances

- immersion in iodophors or sodium hypochlorite for 10 mins.
- Disinfection of baseplates of removable orthodontic appliances by
using 0.12% chlorhexidine spray once or twice a week reduced the
contamination by Mutans Streptococci on the acrylic surface.

Storage of sterilized instruments

Sterilized instruments are stored in a clean, dry, dust-free area (closed
shelves), not at floor level, on windowsills, or under sinks. They are
protected from debris, drains, moisture, and vermin to prevent
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contamination. Handling of sterile packages should be kept to a

minimum.
Storage of sterilized instruments:
- The oldest sterile should be used first if the packaging material is
intact. This is referred to as the “First in-First out” system of stock
rotation.
Waste management system
Waste management is one of the core ecological challenges to the
modern world, especially to the dental practitioners who deal with
regulated waste every day. Recently, the world is looking forward to
effective dental clinical waste disposal solutions.
non-sharp medical waste
Management of Regulated Medical Waste in Dental
HealthCare Facilities is done by use of color-coded or labeled
container that prevents leakage (e.g., biohazard bag) to contain
non sharp regulated medical waste.
ORTHODONTIC WASTE DISPOSAL PROTOCOL

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Sharp medical waste

Sharps refers to the instruments that can cut or pierce the
human skin and expose the skin to contaminated articles,
resulting in diseases like HIV and Hepatitis. The Sharp dental
clinical waste disposal is done in the rigid, leakage -free
containers “sharp boxes” These containers must be labeled with
a biohazard symbol and color-coded for easy identification.
Proper handling of sharps is essential because common personal
protective barriers, such as gloves, will not prevent needle -stick
accidents.
To minimize the potential for accidents, needles should not be
recapped, bent, broken, or manipulated by unprotected hands.
The use of some types of protective cap holding device or
replacement of the capping sheath by “the scoop technique” with
the syringe held in one hand is required.
Conclusion
Infection control is half the treatment of any practice. It should be
remembered that health care professionals who are supposed to treat
and not infect while dealing with very fragile and viable tissues that
are susceptible to hazardous microorganisms and infections. Patients
seek treatment with lot of “HOPE” on health care professionals and

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the initial step in uplifting their hopes is by “Proper Sterilization &

Infection Control”.

Vaccination of dentist and dental staff

Healthcare professionals should be immunized against

I. Seasonal Influenza (Flu) required yearly.

II. Tuberculosis (TB) clearance.
III. Tetanus, Diphtheria and Pertussis (Tdap) booster within the past
9 years.
IV. Measles, Mumps, Rubella vaccine (or evidence of immunity),
within the past 20 years.
V. Varicella Immunization (or evidence of immunity), within the
past 20 years.
VI. Hepatitis-B Vaccination or Hbs-Ag Hepatitis Titer.
VII. COVID-19 Vaccine and Boosters are required, as recommended
by the CDC.

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References
• Mithun K, Dr & M V, Ashith & Harshitha, V & Pereira, Valerie
& Kumari, Deesha. (2018). Infection Control in Orthodontics: A
Review. Indian Journal of Forensic Medicine & Toxicology. 12.
10. 10.5958/0973-9130.2018.00064.6.
• [Orthodontic Experts]. (2021, March 16). Sterilizing
instruments [Video]. Youtube.
https://www.youtube.com/watch?v=VWbVIbkKNlg
• Jose, N. P., Shetty, S., & Mogra, S. (2013). Infection control in
Orthodontics. Lambert Academic.
• [Science of Biology]. (2020, March 16). Bacteriostatic and
bactericidal antibiotics and their actions [Video]. Youtube.
https://www.youtube.com/watch?v=WSHHfq3EJJY.
• [Lumia Dental]. (2021, March 16). LUMIA DENTAL COVID-19
Prevention - UV-C Light Disinifection [Video]. Youtube.
https://www.youtube.com/watch?v=9YOwE1IzBIQ&t=1s
• Bharti , B., Li, H., Ren, Z., & Zhu, Z. (2022). Recent advances in
sterilization and disinfection technology: A review. Science
Direct, 308 part 3(136404).
https://doi.org/10.1016/j.chemosphere.2022.136404

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