Chapter 1

Introduction, Infection Control and Prescribing

M. Greenwood

Introduction to the dental emergency clinic

The dental emergency clinic (DEC) is an important part of the service provided to patients. It is a demanding environment in which to work for main two reasons. First, many patients who attend such departments have a general tendency to avoid dental treatment and view attending such a department as a last resort. Second, from the point of view of the clinicians who work in such clinics, the clinical spectrum is wide, and although there is no remit to provide a specialist service, the boundaries of knowledge and experience for clinicians in certain areas are approaching this. Clinical staff working in these departments need a wide skill mix.

This textbook aims to summarise important areas of knowledge with which practitioners working in the DEC should be familiar. Modern clinical working often requires adherence to protocols, and a summary of some of the more important current management protocols, together with supporting evidence, is provided in the appendices.

For maximum efficiency in any department that deals with emergencies, a system of triage is immensely valuable. Triage is essentially the process of determining the priority of patients’ treatment on the basis of severity of their condition. Triage should result in determining the order and priority of a patient’s emergency treatment and occasionally their onward transport. In the DEC, emergency situations include those where the airway may be compromised due to infection or trauma. Such patients must be assessed promptly and referred quickly for onward management. Other patients, who may have sustained trauma, need to be assessed expeditiously, particularly from the point of view of airway and vital signs, and also possible head injury and concomitant injuries, which in some cases may take priority over the facial or dental injuries. More detail in relation to the assessment of trauma patients is given in Chapter 7.

Clearly, it is important that the wide variety and, sometimes, the large number of patients that pass through these departments are handled in an appropriate and a safe manner. In no area does this apply more than the area of infection control, the principles of which are discussed in the following sections.

Infection and infection control

Hand care

The most simple and effective method of preventing healthcare-acquired infections is to undertake effective hand hygiene. The World Health Organisation has produced guidelines that have been widely adapted into the ‘5 moments for hand hygiene’. These are summarised in Box 1.1.

Handwashing is clearly important in the prevention of spread of infection in general and has received significant media attention in recent years. This is largely due to the prevalence of methicillin-resistant Staphylococcus aureus (MRSA). S. aureus is a bacterium that lives on the skin and in the nose of approximately one in three of the population. Usually, people who carry MRSA do not require treatment and it is no more likely to cause infection than ‘ordinary’ S. aureus, but different antibiotics are used to treat these patients. Screening for MRSA is carried out for new appointees to healthcare posts and hospital inpatients – but not for outpatients. Effective handwashing is critical in the prevention of spread of MRSA.

The other bacterium that has received significant attention, particularly in recent years, is Clostridium difficile. This is a bacterium living in the bowel of less than 5% of the healthy adult population. Patients can develop problems if they are brought into contact with contaminated surfaces (which include hands). Unlike MRSA, alcohol gels are not effective against C. difficile spores, and therefore, effective handwashing is mandatory.

It is important that healthcare workers remove all hand jewellery (with the exception of wedding bands), are bare below the elbows and do not wear a wristwatch. All cuts and abrasions should be covered with a waterproof adhesive dressing. It is important that, after handwashing, gloves are worn, and these should be changed between each patient and the hands washed again after removing the gloves. Non-sterile medical gloves can be used for examination purposes, but sterile gloves should be worn for operative procedures.

There is significant individual variation in requirements, but the regular use of an emollient hand cream is important to prevent drying of the skin after frequent handwashing. Contact dermatitis can be significant enough in some practitioners to cause real practical problems with clinical practice. Most organisations now routinely use latex-free gloves as standard.

Sterilisation and disinfection

Sterilisation is defined as the killing or removal of all viable organisms. Concern about the transmissible spongiform encephalopathies such as Creutzfeldt–Jakob disease (CJD) and particularly variant-CJD has improved the level of understanding of prion disease. This has led to a necessary redefinition of sterilisation as the inactivation or removal of all self-propagating biological entities.

Disinfection is the reduction in viable organisms to the point where risk of infection is acceptable.

Antisepsis is a related term, defined as the disinfection of skin or wounds. It is not practically possible or even necessary to sterilise absolutely everything in a dental surgery. Clearly, all surgical instruments must be sterile and anything coming into direct contact with the surgical site should also be sterile. Everything else should be disinfected.

Sterilisation and disinfection methods

Before any attempt is made to sterilise or disinfect an instrument, macroscopically evident contamination should be removed. If this is not done, physical access of the sterilising or disinfecting agent to the object being sterilised may be prevented. Therefore, instruments should be pre-cleaned and, if they have been in contact with infectious material, pre-cleaning should include adequate disinfection as a first step.

Methods of sterilisation and disinfection include dry or moist heat, a wide variety of gaseous or liquid chemicals, filtration and ionising radiation. The choice depends largely on the nature of the material being treated, the degree of inactivation required and the organisms involved.

In contemporary practice, procedures are followed that are known to result in sterility for different batch sizes and materials. The performance of equipment in terms of the temperature and duration is carefully monitored. The Bowie–Dick tape is one method of ensuring that an autoclave has been functioning effectively. The cross-hatchings turn brown when sterilisation has been achieved (Figure 1.1). Figure 1.2 shows that the sterilisation has been effective within the packaging itself as the coloured area has changed from yellow to blue.