1
Q
What is a health care associated infection (HAI)?
A
An infection that occurs as a result of medical care, or treatment in any healthcare setting
2
Q
What are the ten standard infection control procedures?
A
- patient placement/assessment for infection risk - hand hygiene - respiratory and cough hygiene - PPE - occupational safety - prevention and exposure management (including sharps) - safe management of care equipment - safe management of care - safe management of linin - safe management of blood and body fluid spillages - safe disposal of waste
3
Q
What are the five moments for hand hygiene?
A
- before touching a patient - before an aseptic task - after body fluid exposure risk - after touching a patient - after contact with patient surroundings
4
Q
How should a spillage of blood be dealt with?
A
- apply chlorine granules directly to wet blood spillages - for dry blood, place paper towels on top of spillage area - pour a 10,000 ppm chlorine solution on top of the spillage - leave in contact for three minutes - dispose as clinical waste - additionally wash the surface with hot water and detergent if granules have been used
5
Q
How should a spillage of body fluids be dealt with?
A
- using paper towels remove spillage contents and discard in clinical waste - clean spillage area with 1,000ppm chlorine solution - chlorine should never be used directly on urine or vomit
6
Q
What are the immediate first aid steps for a sharps injury?
A
- squeeze the affected area to encourage bleeding and wash with warm water and soap - splashes to the eyes or mouth should be rinsed out with saline. Remove contact lenses prior to rinsing and seek advice from your optition regarding cleaning
7
Q
What are the four different types of candidosis?
A
*pseudomembranous (thrush) *Erythematous (denture induced stomatitis; atrophic HIV related and candida leukoplakia) *Angular chelitis (poor OH, dry mouth, anaemia, immunocompromised, malnourished, over closed denture) *Hyperplastic (candida leukoplakia)
8
Q
How do you treat pseudomembranous candidosis?
A
*nystatin 4x daily for 7 days *chlorhexidine mouthwash 10ml per rinse for 7 days *fluconazole 50mg daily for 7 days
9
Q
How do you treat erythematous candidosis?
A
*If steriod related use mouthwash after using inhaler *If denture induced stomatitis, ensure thorough cleaning. OHI given. Advise use of milton or chlorhexidine. Ensure denture is removed at night *If drug treatment is required, fluconazole capsules 50mg per day for 7 days, miconazole oromucosal gel on fitting surface of denture
10
Q
How do you treat hyperplastic candidosis?
A
*confirm diagnosis through microbiology and histopathology *systemic antifungals *Iron, folate or viatamin B12 if patient is deficient
11
Q
How do you treat angular chelitis?
A
*chlorhexidine mouthwash 3ml per rinse for 7 days *miconozole (2%) apply to affected area twice daily *sodium fusidate ointment (2%) apply 4 x daily *moconozole and hydrocortisone cream
12
Q
What is the mechanism of action of anti-fungal medication?
A
Azoles mechanism of action is the inhibition of cytochrome P450 dependant enzymes (particularly 14a-demethylase) which is involved in the biosynthesis of erosterol, which is required for fungal cell membrane structure and function. Ensure that miconazole isn’t prescribed to patients taking warfarin or statins
13
Q
What is azole resistance?
A
*it has been found that candida species such as C.krusei and C.Glabrata are naturally resistant to fluconazole *there have also been some stains of C.Albicans that have formed sensitivity and resistance to fluconazole systmeic treatment *this is why it may be important to carry out sensitivity testing and subtyping to ensure what candida species is causing the candidosis
14
Q
What factors influence the use of chlorhexidine?
A
*It contains Bisbiguanide (bactericidal) which is the gold standard for active use against gram positive and negative bacteria, fungi, yeasts and viruses. *There is no known bacterial resistance or superinfection reported with its use *It has 12 hour substantively *It is available without prescription
15
Q
What is the prescribed dose of chlorhexidine?
A
Chlorhexidine digluconate mouthwash 0.2%. 10ml twice daily for 1 - 2 weeks
16
Q
What is the substantivity of chlorhexidine?
A
Substantivity is usually 12 hours but depends on - the absorption to oral surfaces - maintenance of antimicrobial activity - slow neutralisation of antimicrobial activity -other drugs -some food and drinks
17
Q
What are the six indications for using chlorhexidine?
A
* short term use for specific problems such as candidosis *used for cleaning dentures that have caused denture stomatitis * Post oral or periodontal surgery * to prevent oral infections when good OH is difficult to maintain (ie poor manual dexterity) * immunocompromised patients, prevent oral infection spreading systemically * ANUG *Used for treatment of gingivitis as an adjunctive for OH *Used for management of mucositis
18
Q
What side effects are associated with the use of chlorhexidine?
A
Anaphylaxis, hypersensitivity, mucosal irritation, parotid gland swelling, reversible staining of teeth and restorations, taste disturbances, tongue discolouration
19
Q
What is a biofilm?
A
A biofilm comprises of an aggregate of microorganisms, whose cells adhere to one another and embed in a surface. The adherent cells become embedded within a self-produced matrix of extracellular polymeric substances which allows the adherence to a surface.
20
Q
What is a niche?
A
- An ecological niche is the role and position a species has in its environment, how it meets its needs for food and shelter, how it survives and how it reproduces. - A species niche includes all of its interactions with the biotic and abiotic factors of its environment
21
Q
What are the stages of colonisation in a biofilm?
A
- Adhesion - Colonisation - Accumulation - Complex community - Dispersal
22
Q
Give examples of 2 types of Biofilms?
A
- Streptococcus spp. = produce linking film: — Streptococcus mutans in caries development - Actinomyces spp. = cause coaggregation and re-conditioning of the film: — Actinomyces actimomycetemcomitans (A.a) in periodontitis - Candida albicans in candidiasis
23
Q
What 3 factors are required for successful colonisation?
A
- It requires adherence, substrate (energy) and a liveable environment: — Host: i. Mucosa surface, pellicle, acid rich police proteins, minerals and lectins — Saliva: i. Mechanical washing, bactericidal enzymes, buffering and secretor IgA — Bacterial: i. Adhesins, LTA, protease and virulence factors
24
Q
Name five risk factors for developing oral candidosis
A
*immunocompromised patients *immunosuppressive drugs *advanced HIV infections *Intra-abdominal surgery *central venous catheter *broad spectrum antibiotics *Diabetes *long term corticosteroid use
25
What is denture induces stomatitis and what are its signs and symptoms?
candidal infection that adheres to and colonises acrylic surfaces. \*inlammed mucosa, particularly under denture \*burning sensation \*discomfort \*bad taste \*in most cases patients are unaware of the problem
26
name the two most common opportunistic pathogenic yeasts
candida albicans and candida glabrata (differential sensitivities to antifungals. candida albicans generally sensitive to fluconozole)
27
What is the sequence of a biofilm formation?
Attachment - early phase - intermediate phase - maturation phase - dispersal
28
What four key factors account for streptococcus mutans success in causing caries?
\*sucrose metabolism \*adhesions \*polysaccharides \*low pH
29
what is sucrose made into to help s.mutans persist, and how does it do it?
Glucans, glucosyl-transferase
30
How does s.mutans adapt to its acidic environment?
ATPase, altered cell membrane, protection/repair mechanisms
31
What stratagies are there for control of s.mutans?
\*probiotics \*vaccination \*inhibitors \*fluoride
32
What is the significance of porphyromaonas gingivalis?
Gram negative, non motile rod. Strict anaerobe. Black pigmented. Increased numbers in periodontal disease. Suppressed or undetectable in successfully treated lesions. Increased serum of GCF in PD
33
What are the systemic implications of oral biofilms?
Disregulation of the oral mucosal immune system by biofilms. Manifests as destructive inflammation locally and systemically. Increased risk of cardiovascular disease, diabetes, rhematoid arthritis
34
What is dental plaque?
A diverse microbial community (predominantly bacteria) found on the tooth surface, embedded in a matrix of polymers of bacterial and saliva origin
35
Name the three main cariogenic bacteria
\*streptococcus mutans \*Lactobacillus acidophilus \*candida albicans
36
What is the significance of streptococcus mutans?
Gram positive coccus. Metabolises dietary sucrose from insoluble polymers of glucose - sticks to surface. Survive in low pH environments
37
What are the methods of preventing caries
\*Reduce carbohydrate in saliva (dietary changes) \*reduce tooth susceptibility (fissure sealants) \*Reduce or eliminate cariogenic micro-organisms by antimicrobial agents \*increase tooth resistance to acid attack (fluoride)
38
What two main bacteria are associated with endodontic infections?
\*Porphyromonas endodontalis \*Fusobaccterium nucleatum
39
Name some advantages of DNA probes and PCR
\*less time consuming than culture methods \*sensitive \*can directly detect bacterial DNA within clinical samples \*do not require viable cells, samples dont have to be analysed immediately
40
Name some disadvantages of DNA probes and PCR
\*may detect dead cells \*detect only pre-selected species
41
What is a microbiome?
A microbiome includes all the micro-organisms in a particular ecosystem (bacterium, fungus, protozoan, or virus.) Sometimes it is used to describe the total of the genetic material of the micro-organisms in a particular ecosystem
42
Describe caries progression
Adhesion - survival and growth - biofilm formation - complex plaque - acid - caries
43
What are the four main categories of waste?
- Healthcare (including clinical) waste - Domestic waste - Special (hazardous) waste - Sharps waste
44
What are the waste colour categories?
- Black = domestic waste \> landfill - Orange = low risk \> heat disinfection \> landfill - Yellow = high risk \> specialist incineration - Sharps = yellow box (lid colour appropriate) \> specialist incineration
45
What is platelet dysfunction?
— This may be due to a problem in the platelets themselves or to an external factor that alters the function of normal platelets — Platelet dysfunction can be both inherited or acquired with both increasing the risk of excessive and spontaneous bleeding
46
What is Thrombocytopenia
— Is a condition characterised by abnormally low levels of thrombocytes (platelets) in the blood. — Diagnosed when below the normal lower limit of 150x109/L
47
What 3 blood tests can confirm bleeding disorders?
- Full blood count screen – haematology - Coagulation screen – — Prothrombin Time (PT) — partial thromboplastin time (PTT) — Activated partial thromboplastin time (APTT) — APTT ratio — INR — D-dimmer — Fibrinogen - Thrombophilia and haemophilia factor screen
48
What blood test is required for warfarin patients regularly?
- INR screen to determine how long it takes for your blood to clot as warfarin affects vitamin K dependent clotting factors 2,7,9 and 10. - INR 1 = indicates level of coagulation equivalent to an average person not on warfarin but \>1 indicates longer clotting time and thus longer bleeding time - INR \<4 = allows for treatment to occur without interrupting anticoagulant medication; safest between 1.5-2.5
49
List 4 emergency drugs essential for every dental practice
- Adrenaline IM injections (1:1000, 1mg/ml) - Aspirin dispersible (300mg) - Glucagon IM injection (1mg) - Glyceryl trinitrate (GTN) spray (400ug/dose) - Midazolam IM injection (5mg/ml 2ml ampoules)
50
List 4 emergency pieces of equipment essential for every dental practice
- Oxygen cylinder with bag valve mask - Single use sterile syringes - Automated external defibrillator (AED) - Portable powered suction machine with appropriate suction tips and tubing - Oro-pharyngeal airway adjuvants for adults and children
51
Why do we remove air from the process of ultrasonic washing?
— Degassing must occur, if we leave added oxygen/air in the water this inhibits cavitation and a different bubble is formed with less intensity — Without degassing the cleaner would be less effective
52
How often should degassing occur?
- Always run an air purge (degassing) cycle after filling the ultrasonic in the morning to remove air and oxygen from water before cleaning
53
What PPE is required for decon?
- Full face visor, gown, hair mask, marigold gloves and separate shoes that aren’t used for outside.
54
Describe sterilised and sterile
- Sterilised: — When something has went through a process of becoming free from bacteria and all other living microorganisms. - Sterile: — An object that is free from all microorganisms
55
What is sterilisation?
- The use of physical or chemical procedures to destroy all microorganism including large numbers of resistant bacterial spores. - Steam sterilisation: — Is the process used to render reusable medical devices free from viable microorganisms but it does not destroy prions — The aim is to expose the device to steam at a specific temperature for the specific holding time necessary to kill microorganisms — It is ultimately the result of direct contact of medical devices with saturated steam in the absence of air.
56
Define validation
- We consider validation of decontamination equipment when we review if the practice is safe. This related to regulation15 (premises and equipment) and regulation 12 (safe care and treatment). - Maintain and servicing decontamination equipment appropriately is essential to ensure that equipment performs to an optimum standard. This should be done in accordance with the manufacturers instructions.
57
What is the sinner circle?
- It shows the 4 components that are essential for adequate cleaning: — Chemicals — Temperature — Time — Energy (mechanical force) - A reduced parameter is thus compensated by an increase in another or the cycle is inadequate.
58
What’s disinfection?
- The destruction of pathogenic and other kinds of microorganisms by physical or chemical means. - Disinfection is achieved by temperature only known as thermal disinfection - Disinfection is less lethal than sterilisation because it destroys most recognised pathogenic microorganisms but not necessarily all microbial forms such as bacterial spores - Legislation definition: — BS ENO 15883:2006 ad the number of seconds of exposure at 80oC therefore the time heating and cooling while items are above 65oC are taken into account - We disinfect with a washer-disinfector as it makes the load and machine safe for the operator and adds reassurance for the safety of the patient prior to sterilisation
59
What are glycocalyx?
- This is known as a pericellular matrix, which is glycoproteins and glycolipids covering that provides a protected surrounding around the cell membranes of some bacteria, epithelial and other cells. - This allows the bacteria to evade the immune system cells more easily and can incorporate into biofilms. - Bacteria such as staphylococci sp., streptococcus sp., and pseudomonas sp.
60
How do we prevent strep mutans causing caries?
- Reduce carbohydrates in saliva by changing diet habits - Increase tooth resistance to acid attack by addition of fluoride - Reduce tooth susceptibility by fissure sealants - Reduce or eliminate carcinogenic micro-organisms by mechanical removal of the biofilm - Possibility of the use of inhibitors, probiotics, vaccinations and immunisation in the future
61
What is the structure of glucose?
- C6H12O6
62
What are the 3 stages of forming a blood clot?
- Vasoconstriction —\> temporary blockage of a break by a platelet plug —\> blood coagulation/formation of fibrin clot
63
How do anti platelet drugs interrupt the clotting cascade?
- Anti-platelet drugs: — makes platelets less sticky on atherosclerotic plaques — significantly reduce the chance of a heart attack or stroke in at risk people — they prolong the bleeding time following dental extractions which isn’t a significant problem but drug combinations can increase the risk — Aspirin: i. Inhibits platelet aggregation ii. Altering the balance between Throboxane A2 and prostacyclin iii. Irreversible for the life of the platelet iv. Dental treatment normal without interrupting medication
64
How does warfarin affect the clotting cascade?
Warfarin: i. Coumarin based anti-coagulant ii. Inhibits synthesis of vitamin K dependent clotting factors: iii. Factors 2, 7, 9 and 10, protein C and S iv. Initial hyper-coagulation: 1. Anticoagulation takes 2-3 days v. Often heparin used concurrently initially vi. Must be monitored regularly: 1. Drug and food interactions with plasma protein binding and liver metabolism vii. Monitored with INR test: 1. Standardises prothrombin time usually 2-4 viii. Avoid IDB if possible ix. Interactions: 1. All drugs should be assumed 2. Amoxicillin, metronidazole, erythromycin and NSAIDs
65
How do NOACs interrupt the clotting cascade?
— rivaroxaban, Apixaban and Dabigatran: i. All new oral anticoagulants ii. Factor X inhibitors that inhibits conversion of prothrombin to thrombin stopping the producing of the fibrin clot iii. Short-life – effect rapidly lost iv. If it is a short course for DVT – postpone dental treatment until stopped especially extractions v. Dental drug interactions: 1. safe with all except macrolides such as erythromycin and clarithromycin 2. safe with antifungals – topical and fluconazole 3. safe with LA 4. safe with antivirals 5. NSAID will prolong action and inhibit platelets – AVOID
66
What oral signs and symptoms might alert a dentist to undiagnosed diabetes mellitus?
-Candidal infection -Burning mouth syndrome - xerostomia -Rapidly progressing perio disease
67
What is osteoradionecrosis?
-Seen in patients who have received radiotherapy of the head and neck to treat cancer -The bone within the radiation beam becomes virtually non vital -Endarterisis; reduced blood supply -Turnover of any remaining viable bone is slow -Self repair ineffective -Worse in time -Mandible most commonly affected due to poorer blood supply -Routine extraction vs surgical extraction with alveoplasty and primary closure of soft tissue??
68
What are some methods of preventing osteoradionecrosis?
-Scaling/chlorhexidine m/wash leading up to extraction -Careful extraction technique -ABs, chlorhexidine and review -Hyperbaric oxygen (to increase local tissue oxygenation and vascular ingrowth to hypoxic areas) before and after extraction -Take advice/refer patient
69
What are some treatment options for osteoradionecrosis?
-Irrigation of necrotic debris -ABs not overly helpful unless secondary infection -Loose sequestra removal -Small wounds (\<1cm) usually heal over a course of weeks/months -Severe cases; resection of exposed bone, margin of unexposed bone and soft tissue closure -Hyperbaric oxygen
70
What is MRONJ?
-Medication related osteonecrosis of the jaw -Bisphosphonates are a class of drugs used to treat osteoperosis, Pagets disease and malignant bone metastases. -They inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal. -The drugs may remain in the body for years. -Occurs post extraction/following denture trauma/spontaniously -Exclusive to the jaws -Both mandible and maxilla can be affected -Risk is higher in patients receiving IV bisphosphonates but still occurs in patients on oral bisphosphonates
71
How does MRONJ present?
-Non healing wound of \>8 weeks -Ranges from small asymptomatic areas of exposed bone to extensive bone exposure, dehiscence (wound reopening), pus, pain -
72
What factors contribute to the risk of developing MRONJ?
-Length of time the patient has been on drugs -Diabetes -Steroids -Chemotherapy -Smoking
73
What are the treatment options for MRONJ?
-Not very successful -Manage symptoms; remove sharp edges of bone, chlorhexidine, antibiotics if suppuration -Debridement, major surgical sequestectomy, resection, hyperbaric oxygen have not proved successful
74
Name some IV bisphosphonates
-Clodronate -Pamidronate -Zoledronate
75
Name some oral bisphosphonates
-Alendronate -Etidronate -Ibandronate -Risedronate -Tiludronate
76
What medications are linked to MRONJ?
-Antiresorptive drugs including bisphosphonates -Receptor Activator of Nuclear factor Kappa-B ligand (RANK-L) inhibitors such as denosumab (stops production of osteoclasts. -Antiangiogenic, two types \*Monoclonal antibodies that stop receptor or growth factor (bevacizumab) \*Small molecules that determine the block by binding the tyrosine kinase receptor (sunitinib and sorafenib)
77
Describe the clotting cascade
Platelets locally activated \> increased adherence to eachother and blood vessel endothelium (primary haemostasis) \> inactive coagulation factors activated \> production of fibrin \> fibrin stabilises primary platelet plug by cross linking platelets to eachother and damaged blood vessel (secondary haemostasis)
78
Name some antiplatelet drugs and their mode of action
Aspirin, dipyridamol and clopidogrel. -interfere with platelet aggregation by reversibly or irreversibly inhibiting various steps in the platelet activation required for primary haemostasis
79
Name some anticoagulant drugs and their mode of action
Warfarin and other vitamin K antagonists -inhibit the production or activity of the factors that are required for the coagulation cascade -Warfarin inhibits the vitamin K dependent modification of prothrombin and other coagulation factors, impairing secondary haemostasis
80
Give some disadvantages of warfarin
-Narrow therapeutic range -Diet sensitive -Drug interactions
81
Name some NOACs (novel oral anticoagulants) and their mode of action
-Dabigatran; direct inhibitor of the coagulation factor thrombin -Apixaban and rivaroxaban; inhibit factor Xa of the coagulation cascase
82
What are some advantages of NOACs over traditional treatments?
-More predictable level of anticoagulation -Do not require monitoring -Easier to manage -Potentially more effective and safer
83
How should a patients prescription of NOACs be altered for dental treatment?
84
What is the sinner circle?
- It shows the 4 components that are essential for adequate
cleaning:
— Chemicals
— Temperature
— Time
— Energy (mechanical force)
- A reduced parameter is thus compensated by an increase in
another or the cycle is inadequate.
3rd year dentistry
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