PPI di Unit Gigi

PPI di Unit GigiPurnomo HadiMikrobiologi FK UNDIPCDC. MMWR 2003;52(No. RR-17)http://www.cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm

Latar belakang:Pasien maupun petugas perawatan gigi/dental health care personnel (DHCP) dan terpaparpathogensRisiko kontak dengan:darah, sekresi mulut, sekresi pernafasanoral peralatan terkontaminasiProsedur yang tepat dapat mencegah transmissi infeksi antara pasien dan DHCP

Cara TransmisiKontak langsung dengan darah atau cairan tubuh lainKontak tidak langsung dengan alat atau permukaan terkontaminasiKontak dengan selaput lendir pada mata, hidung, atau mulut dengandroplets atau percikanInhalasi mikroba airborne

Rantai InfeksiPathogenSourceModeEntrySusceptible Host4Infection through any of these routes requires that all of the following conditions be present: An adequate number of pathogens, or disease-causing organisms, to cause disease.A reservoir or source that allows the pathogen to survive and multiply (e.g., blood).A mode of transmission from the source to the host.An entrance through which the pathogen may enter the host.A susceptible host (i.e., one who is not immune). The occurrence of all these events is considered the chain of infection. Effective infection control strategies prevent disease transmission by interrupting one or more links in the chain of infection.Standard PrecautionsDiterapkan pada semua pasienKewaspadaan terhadap penularan mikroba dari darah dan juga:Cairan tubuh, sekresi, maupun ekskresi, kecuali keringatKulit yang tidak utuhSelaput mukosa5Previous CDC recommendations on infection control for dentistry (1986, 1993) focused on the use of Universal Precautions to prevent transmission of bloodborne pathogens. Universal Precautions were based on the concept that all blood and certain body fluids should be treated as infectious because it is impossible to know who may be carrying a bloodborne virus. Thus, Universal Precautions should apply to all patients. The relevance of Universal Precautions applied to other potentially infectious materials was recognized, and in 1996, CDC replaced Universal Precautions with Standard Precautions. Standard Precautions integrate and expand Universal Precautions to include organisms spread by:Blood.All body fluids, secretions, and excretions except sweat, regardless of whether they contain blood.Non-intact skin.Mucous membranes.Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between Universal Precautions and Standard Precautions.

Element Kewaspadaan StandardCuci tanganPenggunaan sarung tangan, masker, pelindung mata, dan gaunPeralatan perawatan pasienPermukaan lingkunganPencegahan luka

6Standard Precautions include:Handwashing.The use of personal protective equipment, such as gloves, masks, eye protection, and gowns, that are intended to prevent the exposure of skin and mucous membranes to blood and other potentially infectious materials.Proper cleaning and decontamination of patient care equipment.Cleaning and disinfection of environmental surfaces.Injury prevention through engineering controls or safer work practices.

Note: OSHA retains the use of the term Universal Precautions because they are concerned primarily with transmission of bloodborne pathogens.

Elemen PPI untuk Personnel KesehatanPendidikan dan latihanImunisasiMenejemen pencegahan paparan dan paska-paparanMenejemen kondisi medis dan penyakit yang berhubungan dengan pekerjaanPemeliharaan rekaman kesehatan7Each dental office should have a written plan for an infection control program that includes elements to protect personnel. These elements include: Education programs for staff members. Immunization plan for vaccine preventable diseases. Exposure prevention and postexposure management, with follow-up of staff exposed to infectious organisms or potentially harmful materials. Medical condition management and work-related illnesses and restrictions. Maintenance of health records in accordance with all applicable state and federal laws.

PPI Penyakit Menular lewat darahContoh Penyakit:hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV)

Karakteristik:Dapat ditularkan di kegiatan pelayanan kesehatanDapat menyebabkan penyakit kronisSering dibawa oleh seseorang yang tidak menyadari terinfeksi

8Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are of concern to dental health care personnel (DHCP). These viruses: Can be transmitted to patients and health care personnel (HCP) in health care settings. Can produce chronic infection. Are often carried by persons unaware of their infection. Potensi rute penularan dari Bloodborne PathogensPasienDHCPDHCPPasienPasienPasien9Theoretically, transmission of bloodborne pathogens may occur from patient to DHCP, from DHCP to patient, and from patient to patient. Because DHCP frequently are exposed to blood and blood-contaminated saliva during dental procedures, they are at greater risk of infection by a bloodborne pathogen than are patients. Concentration of HBV in Body Fluids High Moderate Low/Not Detectable

Blood Semen Urine Serum Vaginal Fluid Feces Wound exudates Saliva Sweat Tears Breast Milk10As mentioned earlier, one factor to consider in assessing the risk of infection is the type of body substances to which DHCP are exposed. This slide shows the concentration of HBV in various body fluids. On the left, in red, are the fluids with the highest concentration of virus. Moving from the left to the right side, the concentration decreases. Blood, for instance, has a higher virus concentration than urine or sweat. Saliva alone, without blood, has a moderate concentration of virus.Konsentrasi HBV pada cairan tubuhTinggiModeratDarahSerumCairan luka

SemenCairan vaginaSaliva

Rendah/Tidak terdeteksiUrineFaecesKeringatAir mataASI

Estimasi Insiden InfeksiHBV diantara HCP dan Populasi Umum, United States, 1985-1999

Health Care PersonnelGeneral U.S. Population12In the early to mid-1980s, health care personnel (HCP) had a much higher incidence (i.e., the number of new infections each year) of HBV infection than the general population. By the early 1990s, however, the incidence among health care personnel had dropped below that found in the general population. This decrease likely is the result of increased use of Universal Precautions and the hepatitis vaccine.Source: Cleveland et al., JADA 1996;127:1385-90. Personal communication ADA, Chakwan Siew, PhD, 2005.PercentInfeksi HBV pada U.S. DentistsYear

13Among U.S. dentists, evidence of past HBV infection decreased from prevaccine levels of 14% in 1972 to ~9% in 1989. Since then, levels have remained relatively unchanged. This is because the prevalence (proportion) of HBV infection among all dentists should gradually decrease as older dentists (who are more likely to be infected and unvaccinated than younger dentists) retire.Kepentingan Hand Hygiene:Tangan merupakan cara utama penularan infeksiMenurunkan penyebaran MDROMencegah HAIs

14Next we turn to the subject of Hand Hygiene. So, is hand hygiene the single most important factor in preventing the spread of pathogens in health care settings? First, hands are the most common mode of pathogen transmission. Hand washing can reduce the spread of antibiotic resistance in health care settings and the likelihood of health care-associated infections.

[Additional comments: CDC estimates that each year nearly 2 million patients in the United States acquire infections in hospitals, and about 90,000 of these patients die as a result.]

Personal Protective Equipment(PPE)/APDKomponen major Kewaspadaan StandardMelindungi kulit dan selaput mukosa terhadap pemaparan materi infeksius yang memercik atau menyemprotHarus dibuka ketika meninggalkan area perawtan

15Personal protective equipment (PPE), or barrier precautions, are a major component of Standard Precautions. Use of rotary dental and surgical instruments (e.g., handpieces, ultrasonic scalers) and air-water syringes creates a visible spray that contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a short distance and settles out quickly, landing either on the floor, operatory surfaces, dental health care personnel (DHCP), or the patient. PPE is essential to protect the skin and the mucous membranes of DHCP from exposure to infectious or potentially infectious materials. PPE should be worn whenever there is potential for contact with spray or spatter and should be removed when leaving treatment areas.

Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Sterilisasi dan disinfeksi Peralatan Perawtan pasienPeralatan KritisPeralatn semi kritisPeralatan non-kritisInstrument Processing AreaDirancang agar terkendali kualitas dan keamananannyaDipisahkan dalam beberapa area kerja: Receiving, cleaning, and decontamination Preparation and packaging Sterilization Storage

17Most instrument cleaning, disinfecting, and sterilization should occur in a designated central processing area to control both quality and personnel safety. To prevent cross-contamination, the instrument processing area should be physically or spatially divided into regions for cleaning, packaging, sterilization, and storage. In the cleaning area, reusable contaminated instruments are received, sorted, and cleaned. The packaging area is for inspecting, assembling, and packaging clean instruments in preparation for final sterilization. The sterilization and storage area contains the sterilizers and related supplies, incubators for analyzing spore tests (if performed in officealthough some states require using a testing service), and can contain enclosed storage for sterile items and disposable (single-use) items.

Kategori Lingkungan Permukaan Permukaan kontak klinikSangat berpotensi terkontaminasi langsung dari semprotan atau percikan atau kontak dengan sarung tanganDHCPsPermukaan perabot rumahTidak kontak dengan pasien atau peralatanKemungkinan kecil menularkan penyakit18There are two categories of environmental surfaces.Clinical contact surfaces have a high potential for direct contamination from patient materials either by direct spray or spatter generated during dental procedures or by contact with DHCPs gloved hand. These surfaces can later contaminate other instruments, devices, hands, or gloves.

Housekeeping surfaces do not come into contact with patients or devices used in dental procedures. Therefore, they have a limited risk of disease transmission.

Clinical Contact Surfaces

19This slide shows some examples of clinical contact surfaces, including a light handle, countertop, bracket tray, dental chair, and door handle (shown by arrows).

Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Housekeeping Surfaces

20Examples of housekeeping surfaces are walls, sinks, and floors (shown by arrows).

Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Sampah MedisTidak infeksius: anggap sebagai sampah domestik biasaRegulated Medical Waste: Jenis sampah yang mempunyai risiko infeksi selama penanganan maupun pembuangan

21There is no evidence that traditional medical waste management has contributed to increased levels of disease in the community or among health care personnel. The majority of waste generated in a medical or dental office (~98%99%) is not considered infectious and can be discarded in the regular trash. Examples include used gloves, masks, and lightly bloodied gauze.Some waste, such as used needles, extracted teeth, and gauze soaked in blood, may pose a potential risk of infection, however, and warrants special precautions during handling and disposal. Follow federal, state, and local regulations for proper treatment and disposal.

Dental Unit Waterlines, Biofilm, and Water Quality22Dental Unit Waterlines (DUWL), Biofilm, and Water Quality.Saluran air dan Biofilm di Unit Gigi:Biofilm: microbial biofilms terbentuk pada lubang kecil bore dari dental units Merupakan sumber mikroba

Pusat pasokan air (PDAM) merupakan sumber utama mikroba

23Studies have shown that colonies of microorganisms, or biofilms, can form on the inside of the small-bore plastic tubing that transports water within the dental unit to handpieces and air-water syringes. Once formed, a biofilm serves as a reservoir that may dramatically increase the number of free-floating microorganisms in water used for dental treatment. Most organisms isolated from dental water systems originate from the public water supply and do not pose a high risk of disease for healthy persons. Although a few pathogenic organisms, such as Legionella spp. and Pseudomonas sp., have been found, adverse public health threats have not been documented.

Photo credit, top: CDC Image library. This Scanning Electron Micrograph depicts an E. coli (ATCC 11775) biofilm grown on PC (polycarbonate) coupons using a CDC biofilm reactor.Photo credit, bottom: Illustration from the Center for Biofilm Engineering, Bozeman MT.Dental Unit Water QualityUsing water of uncertain quality is inconsistent with infection control principlesColony counts in water from untreated systems can exceed 1,000,000 CFU/mL CFU=colony forming unitUntreated dental units cannot reliably produce water that meets drinking water standards

24Despite a lack of documented adverse health effects, using water of uncertain microbiological quality is inconsistent with infection control principles. Levels of contamination in water from untreated systems can exceed 1 million colony forming units per milliliter (mL) of water.Untreated dental units cannot reliably produce water that meets drinking water standards (fewer than 500 CFU/mL of heterotrophic water bacteria). Even using source water containing 500 CFU/mL of bacteria (e.g., tap, distilled, or sterile water) in a self-contained system will not eliminate bacterial contamination in treatment water if biofilms in the water system are not controlled. Removal or inactivation of dental waterline biofilms requires use of chemical germicides.

Kualitas Air Unit Gigi

Untuk penangnan gigi standar, sama dengan persyaratan standar untuk air minum.*

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