E-Book, Englisch, Band 39, 76 Seiten
E-Book, Englisch, Band 39, 76 Seiten
Reihe: QuintEssentials of Dental Practice
ISBN: 978-1-85097-322-5
Verlag: Quintessence Publishing Co. Ltd.
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)
Autoren/Hrsg.
Weitere Infos & Material
Chapter 1: The Risks
Chapter 2: Medical Histories and Personal Protection
Chapter 3: Surgery Design and Surgery Equipment
Chapter 4: Instrument Decontamination
Chapter 5: Disinfection
Chapter 6: Legal and Ethical Issues in Infection Control
Appendix 1: Model Policies, Protocols and Checklists
Appendix 2: Syllabus for Infection Control Training for Members of the Dental Team
Index
Chapter 2
Medical Histories and Personal Protection
Aims
The first aim of this chapter is to examine the value of the patient’s medical history in preventing the transmission of infection during dental procedures. The second aim is to look at personal protection of dental personnel. Outcome
After reading this chapter, you should have an understanding of the use of the medical history and how personal protection is important in prevention of the transmission of infection. Medical Histories
Taking an accurate medical history is essential before any dental procedure, but often is not helpful for determining whether a patient is an infection risk. This is because many of the potentially infectious diseases are “silent” – the patient may not know they have contracted them. Thus, unless the patient reports that they have been diagnosed as carrying a specific infectious disease, the medical history may not be helpful in determining their infectious status. Many potentially infectious diseases are associated with prejudice and stigma, notably HIV, and infected patients may as a consequence be economical with the truth in giving their medical history. In addition, in many countries, patients are not obliged by law to disclose information about certain infectious diseases they know they carry. One frequently asked question in taking medical histories is to ascertain a history of jaundice. Although this question can be helpful in determining whether a person has liver disease, which can affect, for example, bleeding time, it is rarely helpful in eliciting liver infections, such as hepatitis B or C. A history of jaundice can also be unhelpful, because it could have been caused by hepatitis A or E, conditions which are usually self-limiting and do not pose an infection risk in dentistry. Jaundice is usually a late stage in the progression of hepatitis B and C infections. It is therefore unlikely that carriage of hepatitis B or C would be elicited from a medical history, unless the patient has been diagnosed as having contracted them and reports them truthfully. It is because the medical history may be non-contributory in determining whether the patient is an infection risk that standard precautions are used for all patients. Even if a patient does not report a significant diagnosed infection when the medical history is taken, if standard precautions are used, these should give protection against infection for all normal dental procedures. Confidentiality
Any information given to a dental professional during a medical history must be completely confidential. All staff must be aware of this absolute need for confidentiality. Worldwide there have been a number of cases of breaches of confidentiality that have resulted in legal redress. Infection Control Policy and Staff Training
Every dental practice should have a written and regularly updated infection control policy, which has been read and is adhered to by all members of staff (see Chapter 6 and appendices). It should be a condition of employment that all staff adhere to the policy. An example of an infection control policy is shown in Appendix 1. The policy should include a daily schedule of how to set up a surgery for various procedures (see Appendix 1). New members of staff should have full induction training in infection control (see Appendix 2) and should not learn just by observation during dental procedures. The compliance of all staff with infection control procedures should be regularly audited and discussed at practice meetings. In addition, all staff should periodically attend training sessions given by experts from outside the practice. Pre-employment Health Checks for Dental Personnel
Countries vary in their legal requirements for pre-employment health checks for dental personnel. In some countries any personnel who have contracted HIV, hepatitis B, C or tuberculosis are prevented by law from doing, or assisting in dental operations. The evidence for preventing an untreated tuberculosis carrier from being involved in dental procedures is compelling, but after four weeks of a course of antituberculosis therapy they should not be any danger of transmission of infection. The case for barring a person who is infected with HIV is less conclusive, as highly active retroviral therapy should negate the very minimal risk of transmission. Many countries do not legally prevent HIV carriers from doing dental procedures, provided standard precautions are taken, appropriate medication used and regular health checks are done on the infected individual. Similarly hepatitis C has never been proven to be transmitted by dental personnel and it seems illogical to ban carriers from participating in routine dental procedures. The main route for transmission of hepatitis B to dental personnel is from patient’s blood on instruments after sharps injuries. It is probably related to the number of virions present in the blood. This can be assessed by estimating the number of hepatitis B DNA copies present in a unit of blood. Some countries recommend that dental personnel, if they are doing invasive dental procedures, should not have greater than 103 virions per ml present in blood but this condition is not universally employed. The value of pre-employment health checks for HIV and hepatitis C is therefore questionable, but there is some merit in ensuring that carriers of hepatitis B and tuberculosis do not engage in invasive dental procedures. Immunisation against Infectious Disease
Successful immunisation against infectious disease is an essential part of personal protection in dentistry. The immunisations that are commonly recommended are shown in Table 2-1 and cover a range of bacterial and viral disease. Many of the immunisations listed in the table are routine vaccinations against infectious disease given in most developed countries to infants or adolescents, and are not especially applicable to dentistry. Some of these vaccinations are not given routinely in some countries; a good example of this is tuberculosis. The use of an avirulent tuberculosis strain in the bacille Calmette-Guérin (BCG) vaccine has not been accepted by all countries, as its efficacy of protection and longevity has been questioned. Table 2-1 Vaccinations recommended for dental staff Disease Route Length of protection Diphtheria Intramuscular Probably lifelong if given in infancy, but some authorities recommend re-vaccination in adolescence Hepatitis B Intramuscular Probably lifelong but some countries recommend re-vaccination every 5 years Pertussis Intramuscular Probably lifelong Poliomyelitis Oral Probably lifelong Tetanus Intramuscular Probably lifelong Tuberculosis Subcutaneous Protection can last for 15 years in some people, but is incomplete Barrier Protection
The hands, eyes and faces of dental personnel are the most vulnerable areas for the transmission of infection and should be safeguarded by barrier protection. Other areas such as dental clothing are more controversial. Hands
The care of the hands is absolutely essential to all dental personnel. Emphasis should be placed on supple, intact skin with no cuts or abrasions and well-cared-for nails and nail beds. This means that dental personnel have to care for their hands, not just while they are working, but at other times too. During hobbies which involve possible damage to the hands, such as gardening and car maintenance, the hands have to be protected. A schema for the protection of the hands is shown in Fig 2-1. At the start of the day, the hands should be carefully examined and any cuts and abrasions covered with an adhesive waterproof dressing. It is essential that rings and watches are removed if detritus is not to accumulate under these items. Those who do not want to remove rings must completely cover them with waterproof adhesive coverings, but this is not ideal. Fig 2-1 Schema for routine handwashing and protection. The hands can now be systematically washed and the easiest way to achieve this is to use a technique such as that described by Ayliffe and illustrated in Fig 2-2. The hands are first wetted all over, soap is applied and then the hands are washed using a systematic technique and then thoroughly rinsed. Careful rinsing is essential as soap draws water and oils out of the skin and if left in situ it can make the skin less pliable. Fig 2-2 The Ayliffe technique for systematic handwashing. The choice of soap is important and a personal choice. Bar soap should never be used as it can get heavily contaminated and can grow bacteria! Combinations of soap and disinfectant are effective, but often can damage the hands. Some soap and detergent combinations, such as those containing chlorhexidine, may contain chelating agents which may cause skin irritation, let alone stop the disinfectant from coming out of solution. The emphasis in initial handwashing for dental procedures is that the hands should be thoroughly cleaned; a disinfectant may be useful but is not essential. Everyone’s skin is a little different and experimentation is necessary to find the optimum agent for personal hand cleaning. Once clean, the hands are thoroughly rinsed and...
