MODULE 2: PATHOGENS
Infection Control
Dr. Alden Aguilar
Introduction
The Center for Disease Control defines
pathogens as a group of microorganisms –
bacteria, fungi, virus and parasites that cause
disease in human beings. Pathogens present
in the blood and may contaminate the skin,
enter the conjunctiva, nasal and oral mucosa
by either direct and indirect contact or
through inhalation of droplets from an infected individual.
Transmission of infectious disease results from the
interaction of agent, host and environment.
Lesson 1: Pathogens
The dental setting with its personnel has been recognized
by the Center for Disease Control has the greatest risk of
exposure in a wide variety of microorganism that is present
in the blood and saliva of their patients being treated.
A pathogen is an organism that causes disease. In order for
a microorganism to cause an infection it must attach to the
host’s targeted cells, penetrate the surfaces of the body and
establish themselves leading to cell destruction. While the
body is well protected from microbial invasion by an intact
skin, the mucosa lined orifices of the body are sites for the
potential entry of infection caused by these microorganisms.
Depending on the type, these pathogens can spread and
cause infection.
Transmission of Infection in the Dental Office Environment
Infection may be transmitted in the dental operatory by
blood or saliva through direct contact, droplets or aerosol.
Patients and dental health care workers have the potential
of transmitting infections to each other.
Transmission of Microbes in the dental office environment
will depend on:
1. pathogenicity of microorganism
2. ability of the microorganism to survive in the
environment
3. route of transmission
Transmission of infection in the dental set
up is through aerosol with the use of
dental equipment such as air rotor or
mechanical scaler which produces high energy fine spray
that can pick up microbes from patients's oral tissue and
distribute them in the environment.
Another way in which transmission of pathogenic
microorganism can occur in the dental office is through the
equipment or work surfaces known as fomites. Microbes
have poor adherence to the surface of materials such as
stainless steel used in dental instruments or to smooth
surface materials. However, if these surfaces are
contaminated with organic materials such as blood, saliva
or body secretion, adherence will be greatly enhanced.
Therefore, a delay in cleaning of the contaminated surface
will lead to an increase in the number of bacteria present.
In a good infection control practice, all surfaces that have a
potential risk of contamination should be cleaned regularly
and particularly before and between all patient treatment
occasions.
As a healthcare provider, dental workers must understand
the influence of these mode of transmission and strictly
implement safety protocol measures to reduce the spread
of infection in the clinical area.
Virus
- are made up of a piece of
genetic code, such as DNA or
RNA, and protected by a
coating of protein.
- Once you are infected,
viruses invade host cells within your body. They use
the components of the host cell to replicate,
producing more viruses. Viruses are different to
bacteria in that they are strict parasites and rely
completely on the host’s cells to multiply and
survive
- After the replication cycle is complete, the host cell
will be so full of copied viruses that it will burst open
releasing large numbers of viruses that will then go
on and infect further target cells either in the host
or will be shed from the host and will go on to infect
further individuals. This process results in
widespread destruction of the host tissues causing
the signs and symptoms of the disease
- Antibiotics do not kill viruses and therefore are
ineffective as a treatment for viral infections.
Antiviral medications can sometimes be used,
depending on the virus.
➢ In Dentistry, oral viral infections manifest itself as
either ulceration or blistering of the oral tissues.
Evidence of viral transmission in the dental office
has created awareness to oral healthcare workers
to be knowledgeable of the symptoms so available
health care protocols may be practiced.
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Bacteria
- are microscopic, single-celled
organisms that thrive in diverse
environments.
- These organisms can live in
soil, the ocean and inside the human gut. Bacteria
are motile and have the ability to ‘swim’ and
multiply when in a moist environment.
- Sometimes bacteria lend us a helping hand, such as
by curdling milk into yogurt or helping with our
digestion. In other cases, bacteria are destructive,
causing diseases like pneumonia and
methicillin-resistant Staphylococcus aureus (MRSA)
and tuberculosis.
➢ In the discipline of Dentistry, a bacterial infection
causes demineralization and destruction of the
hard tissues enamel, dentin, and cementum) that
can lead to dental caries. The bacteria most
responsible for dental cavities are the mutans
streptococci, most prominently Streptococcus
mutans and Streptococcus sobrinus, and
lactobacilli. If left untreated, the disease can lead to
pain, tooth loss, and infection. Today, caries remain
one of the most common diseases throughout the
world.
Fungi
- There are millions of species of fungi on Earth. It
can be found anywhere in the environment,
including indoors, and human skin. When they
overgrow, they cause an infection.
- Fungi cells contain a nucleus protected by a
membrane and a thick cell wall. Their structure can
make them harder to kill. An undiagnosed fungal
disease can lead to serious illness and death. A key
clue to when a sick person may have a fungal
disease is that he or she is being treated with
medicine for another type of infection but does not
get better.
➢ Fungal infections, although uncommon in dental
practice, may indicate a more serious systemic
illness. Oral candidiasis is the most common fungal
infection encountered in
dentistry.
Parasites
- Parasites are organisms
that behave like tiny
animals. They live and feed from at the expense of
the host
- Parasites usually enter the body through the mouth
and skin.
- Parasites that enter through the mouth are
swallowed and can remain in the intestine or
burrow through the intestinal wall and invade other
organs. Often parasites enter the mouth through
fecal-oral transmission.
- Some parasites can enter directly through the skin.
Others are transmitted by insect bites.
➢ Once upon a time, dental patients believed a
toothache was caused by a tooth worm eating
away their tooth from the inside out. Modern-day
medical science has proven that there is no such
parasite and that the concept is merely superstition.
But evidences of oral protozoa has been identified
and studied in cases of gingivitis and periodontal
diseases.
Infection Control
There are several steps you can take to lower your risk of
contracting a parasitic infection:
● Practice safe sex, using a condom.
● Wash your hands regularly, especially after
handling uncooked food or feces.
● Cook food to its recommended internal
temperature.
● Drink clean water, including bottled water when
you’re traveling.
● Avoid swallowing water from lakes, streams, or
ponds.
● Avoid cat litter and feces when you’re
pregnant.
Lesson 2: Blood Borne Diseases of Concern to Dentistry
​ loodborne pathogens are
B
microorganisms such as
viruses or bacteria that are
carried in blood and can cause
disease in people. Bloodborne
pathogens such as HBV and
HIV can be transmitted through contact with infected human
blood and other potentially infectious body fluids. In
Dentistry, these pathogens are transmitted from saliva and
blood from dental procedures or from accidents arising
from a dental procedure.
Human Immunodeficiency Virus (HIV)
Dental health care personnel should strive to
create a safe, welcoming and nonjudgmental
environment for all patients in order to encourage
dental care
● Infection with human immunodeficiency virus
(HIV) predisposes people to certain oral health
problems
● Patients who are HIV-positive can receive
routine dental care.
● Dentists and all staff with direct patient contact
should follow Standard Precautions with all
patients.
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Human Immunodeficiency Virus, commonly known as HIV, is
a virus that can eventually become AIDS if left untreated.
AIDS, which stands for Acquired Immunodeficiency
Syndrome, will eventually lead to death. Currently there are
no treatments that can completely cure the HIV virus, so
once you are infected, you will have it for life.
HIV is classified as a retrovirus and works by targeting the
body’s immune system, specifically CD4 T cells, making it
difficult for the body to fight off infections. Eventually the
body will succumb to opportunistic infections, which leads
to death. HIV usually progresses very slowly, often taking
years for a person to exhibit signs and symptoms.
Although HIV cannot be cured at this time, but there are
treatments designed to slow the progression. ART, or the
antiretroviral therapy has dramatically helped decreased
the number of lives lost with HIV. The goal of ART is reduce
the viral load in a patient’s body, therefore reducing your
chance of transmission to others.
MODE OF TRANSMISSION
● HIV is transmitted most
commonly from anal
or vaginal sex and
through the sharing of
needles or syringes
● Rarely transmitted
through oral sex, blood
transfusions, or organ/tissue transplants
● It is also possible for HIV to be transferred from
an HIV-positive mother to her baby during
pregnancy, birth or breastfeeding, although
this is also rare.
X HIV is not transmitted through casual
touching, sharing toilets, closed-mouth kissing,
saliva, tears, sweat, or insects
Relevance to Dentistry
● Patients that are HIV positive can be treated
routinely in the dental office as long as standard
precautions are followed by the practitioner and
staff.
● It is important to obtain a detailed medical history
from the patient as well as their most recent lab
values and to determine their current disease
status. A high CD4 T cell count and low viral load
would indicate an effective treatment regimen.
● Dental treatment may be affected if a patient is
severely immunocompromised as wound healing
would likely be impaired.
● A patient with a very high viral load would also
be more likely to be contagious, so elective
treatment may be delayed until this is brought to
more manageable levels.
INFECTION CONTROL
1. Avoiding exposure to blood and bodily fluids is the
primary way to prevent transmission of HIV in
dental care settings.
2. During dental procedures, saliva tends to become
contaminated with blood, increasing the risk of HIV
transmission from saliva.
3. Standard precautions should be followed with all
patients, whether or not they have been diagnosed
. Dental personnel should wear barrier precautions
(e.g., gloves, masks, and protective eyewear).
4. The occupational source of greatest risk of HIV
transmission is percutaneous injuries. Dental
personnel can reduce their risk of percutaneous
injuries by following the Standard Precautions,
having engineering controls and work-practice
controls for all sharps, and following safe injection
practices.
Hepatitis Viruses
● Hepatitis A (HAV),
hepatitis B virus
(HBV), and
hepatitis C virus
(HCV) are
prevalent and
infectious causes of liver disease.
● HBV infection is preventable through
vaccination, most commonly administered in 2
or 3 injections over the course of 6 months.
● Although there is no vaccine for HCV, current
treatment regimens can cure more than 90%
of cases.
● Careful medical histories can capture insight
about patients to help identify those potentially
posing infection risk.
● Dentists and all staff with direct patient contact
should comply with all standard precautions
(e.g., wearing appropriate personal protective
equipment and disinfecting all equipment and
surfaces after each patient) for all patients.
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Hepatitis A Virus (HAV)
● HAV is acquired in the U.S. primarily through close
personal contact with an infected person and
during foodborne outbreaks. Unlike HBV and HCV,
HAV does not cause chronic infection.
Hepatitis B Virus (HBV)
● Hepatitis B (HBV) is a member of the hepadnavirus
family. HBV infects mainly the liver but can also
infect the kidneys and pancreas . HBV is a small,
enveloped DNA virus. It is a particularly stable virus,
making it very resistant to disinfection. This makes
HBV able to live for a long time outside of the body,
therefore making cross contamination and infection
much more likely. It can survive outside the body
for at least 7 days and still be capable of causing
infection.
Hepatitis C Virus (HCV)
● Hepatitis C (HCV) is a blood-borne virus of the
family Flaviviridae that often results in chronic liver
infection. HCV is a small, enveloped RNA virus that
targets human hepatocytes . For some people, the
infection is acute and they are able to clear it on
their own, but in 70–85% of cases, it becomes a
chronic infection. Most people who become infected
are not aware because they do not show any signs
of illness. Chronic infection can lead to more serious
complications such as liver cirrhosis, hepatocellular
carcinoma, and even death.
Mode of Transmission
Hepatitis A Virus (HAV)
● Person to person contact
● Contaminated food or water
● Very rarely blood exposure
Hepatitis B Virus (HBV)
● HBV is transmitted perinatally, percutaneously,
and through sexual contact.
● It is also spread through open cuts and sores
through individuals in close contact
● HBV infection is more commonly seen in
adulthood as a result of sexual transmission
and IV drug use .
● X It is not spread through breastfeeding, food,
water, casual touching, kissing, or droplets
from coughing or sneezing
Hepatitis C Virus (HCV)
● It can be transmitted in blood, semen, and
vaginal secretions.
● This is most commonly seen in patients
receiving transfusions or organs, needlesticks
in the healthcare setting, sharing drug needles
and through sexual intercourse.
● Almost all those infected with HIV (greater than
90%) who are or were intravenous drug users
are also infected with HCV
Relevance to Dentistry
● Percutaneous injuries are the most efficient mode
of HBV transmission, but the majority of HBV
infections among dental practitioners occur from
infected blood or body fluids coming in contact with
mucosa or existing breaks in the surface of the skin.
● Dental professionals had a three- to four-fold
higher risk of HBV infection than in the general
population. Vaccines and precautionary methods
have contributed to decrease that risk . For adults,
the vaccine is given in two or three injections. If
there is an interruption between HBV vaccine
doses, the series does not need to be restarted, but
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 the next dose should be administered as soon as
possible.
● Those who are unsure whether they have been fully
vaccinated can test their immunity to HBV through
serologic assays.
HCV can be transmitted through a percutaneous injury
(such as a needlestick or cut with a sharp object) or contact
between mucous membranes or non-intact skin with blood,
tissue, or other bodily fluids. After a needlestick exposure to
HCV-positive blood, the risk of HCV infection is
approximately 1.8%.
HCV has been detected in saliva, but no undisputed case of
HCV salivary transmission has been documented.11
Unlike HBV infection, there is no effective vaccine or
post-exposure prophylaxis available for HCV infection. Prior
infection with hepatitis C does not protect against later
infection.
Patient medical histories can assist in the identification of
those potentially infected with viral hepatitis.
Care of patients with acute viral hepatitis should
generally be limited to urgent care.
Infection Control
● To prevent HBV or HCV infection,
dental personnel should follow
standard precautions, which
include wearing barrier
precautions (e.g., gloves, masks,
and protective eyewear) whenever
there is potential for contact with
body fluids or mucous membranes.
● Use work practice and engineering
controls for sharps safety, and follow
safe injection practices
● Centers for Disease Control and
Prevention’s (CDC’s)
recommendations on infection
control the sterilization and
disinfection of dental equipment
and instruments.
● Disinfecting the dental care
environment after any contact
with potentially infected body
fluids is also important since HCV
can survive at room temperature
on surfaces for more than 5
days, and HBV can survive for at least 1 week. The
CDC recommends cleaning exposed surfaces with a
1:10 dilution of bleach to water.
● Adherence to all infection control recommendations
is vital to preventing the spread of hepatitis.
In the event of an exposure
incident (e.g., needlestick, sharps
injury), employers are required to
refer the exposed employee to a
licensed health care professional
who can provide post-exposure
evaluation and follow-up services
that include: documentation of the exposure; identification
of the source individual; testing of the source individual’s
blood for infectivity status; collection of the blood and
testing; post-exposure prophylaxis, if indicated; counseling;
and a written opinion documenting that the employee was
provided services.
➢ In cases where dental health-care personnel are
acutely infected with HAV, the CDC recommends
that they should be restricted from patient
contact and/or contact with patient
environments until 7 days after onset of
jaundice.
Lesson 3: Other Diseases Of Concern to Dentistry
Herpes Simplex 1-3
● HSV-1 is mainly
transmitted by
oral-to-oral contact to
cause oral herpes
(which can include
symptoms known
“cold sores”), but can
also cause genital herpes.
● Both HSV-1 and HSV-2 infections are lifelong.
● Most oral and genital herpes infections are
asymptomatic.
● Symptoms of herpes include painful blisters or
ulcers at the site of infection.
● Herpes infections are most contagious when
symptoms are present but can still be
transmitted to others in the absence of
symptoms.
Infection with herpes simplex virus, commonly known as
herpes, can be due to either herpes simplex virus type 1
(HSV-1) or herpes simplex virus type 2 (HSV-2). HSV-1 is
mainly transmitted by oral-to-oral contact to cause infection
in or around the mouth (oral herpes). HSV-2 is almost
exclusively transmitted through genital-to-genital contact
during sex, causing infection in the genital or anal area
(genital herpes).
HSV-1 is a highly contagious infection. Most HSV-1 infections
are acquired during childhood, and infection is lifelong.
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Oral herpes infection is mostly
asymptomatic, and most people
with HSV-1 infection are unaware
they are infected. Symptoms of
oral herpes include painful blisters
or open sores called ulcers in or
around the mouth. Sores on the lips
are commonly referred to as “cold sores.”
MODE OF TRANSMISSION
● HSV-1 is mainly transmitted by oral-to-oral contact
to cause oral herpes infection, via contact with the
HSV-1 virus in sores, saliva, and surfaces in or
around the mouth.
● HSV-1 can be transmitted from oral or skin surfaces
that appear normal and when there are no
symptoms present. However, the greatest risk of
transmission is when there are active sores.
● In rare circumstances, HSV-1 infection can be
transmitted from a mother with genital HSV-1
infection to her infant during delivery to cause
neonatal herpes
Relevance to Dentistry
HSV can cause persistent infection and is shed in saliva. There
is also evidence of transmission of HSV to health-care workers
from patients and from dental workers to patients. According
to the Center for Disease Control and Prevention (CDC), there
are two treatments you should be rendering: emergency
treatment for dental conditions and treatment of the
lesions. No other treatment should be rendered.
HSV can survive for hours in fluids and on environmental
surfaces, including counters and dental charts. Dental
handpieces have also been found to be a source of possible
transmission. Gloves are not a complete protection against
this virus. The infection control measure that should be
practiced most often is to simply not see the patient for
elective treatment when there is an active infection.
Infection Control
1. Limit treatment to urgent or
emergency care
2. Delay elective procedures until
lesions are healed
3. Provide treatment designed to reduce the time of
healing
4. Where the use of equipment that produces an
aerosol cannot be avoided, use extreme caution
and extra PPE that fully covers the body (lab
coat or apron), eyes (goggles), and face (facial
shield). Disinfect after use
5. Use a National Institute for Occupational Safety
and Health N95 rated or higher mask if aerosol
may be present (to protect against aerosol
contacting oral mucosa)
6. Even if aerosol danger is minimal, wear
appropriate extra PPE to cover arms, hands, and
to protect face
7. Be aware of the potential for sudden patient
reaction to pain. Unless needed, keep the hand
that is not holding an instrument out of the “line
of fire”
8. Change gloves frequently if the procedure is
lengthy, taking care to wash the hands using
soap and warm water between glove changes
9. Provide eye protection for the patient and
recommend that the patient wash hands and
face after treatment
10. Educate the patient on the nature of herpes
labialis
Tuberculosis
The risk of transmission of tuberculosis in dental settings is
low. The Center for Disease Control and Prevention (CDC)
recommends dental health care personnel include protocols
for tuberculosis infection control in their offices’ written
infection control program.
● Infection occurs through inhalation of
mycobacteria, which then travel to the alveoli
of the lungs; only people with active disease
can spread the infection.
● A person with latent tuberculosis is not
infectious; he or she can be treated in the
dental office under standard infection control
precautions.
● A person with active tuberculosis, standard
precautions are insufficient to prevent
transmission of the bacterium.
Relevance to Dentistry
In 2005, the CDC developed guidelines for preventing
transmission of M. tuberculosis in health-care settings. The
guidelines for infection control reinforces the need for
managing dental environmental surfaces and should serve
as the standard for clinicians to follow regarding surface
disinfection.
INFECTION CONTROL PRACTICES
Additional guidelines as suggested in the research of
Rajasekar et al are as follows:
1. Limit the use of ultrasonic scalers and high speed
handpieces in actively infected patients. High
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 volume suction is mandatory for carrying out any
procedure to minimize aerosol generation.
2. Use rubber dam isolation with high vacuum suction.
However, if the patient has productive cough it is
better to avoid Rubber dam.
3. Maintenance of proper hand hygiene, personal
protective equipments like eye shields, facemasks,
head caps, gloves and surgical gowns.
4. Standard face masks do not protect against TB
transmission, hence particulate face masks should
be used and often changed at regular intervals.
Face masks should have atleast 95% Bacterial
filtration efficiency (BPE) for particles 3µm
diameter. While treating patients with symptoms of
active TB, the operator should wear respirators
rather than routine face masks.
5. TB rooms should have effective air evacuation with
either exhausted or HEPA-filtered if re circulation is
necessary.
6. Regular fumigation of dental operatories. Cleaning
and disinfecting critical and semi critical contact
surfaces like Dental chair and accessories. Anti
bacterial sprays may be used.
7. Use of barrier techniques.
8. Use of high efficacy filters or UV light in the exhaust
air ducts.
9. All dental settings should conduct an annual risk
assessment for TB transmission.
Lesson 3: Emerging Infections of Dentistry
World health was recently shaken by a novel virus which
spreads primarily through droplets of saliva or discharge
from the nose when an infected person coughs or sneezes.
Tracing the time line of the World Health Organization,
Wuhan health authorities reported cases pneumonia last
December of 2019 and eventually identifying a novel
coronavirus. By the end of January WHO authorities, after
analyzing data and information, recommended and
declared the novel coronavirus outbreak (2019-nCoV).
During this time, the first known case of the disease was
confirmed in the Philippines.
The Virus
According to the World Health
Organization
(WHO),coronaviruses make up a
large family of viruses that can
infect birds and mammals,
including humans. This
coronavirus which sports a spiky projections on their outer
surface which resembles the points of a crown have been
responsible for several outbreaks around the world,
including the severe acute respiratory syndrome (SARS)
pandemic of 2002-2003 and the Middle East respiratory
syndrome (MERS) outbreak in South Korea in 2015.
Pathogenicity
According to Jan Carette, an associate professor of
microbiology and immunology at the Stanford University
School of Medicine, a coronavirus's pronged exterior lies a
round core shrouded in proteins and a "greasy" membrane.
The core contains genetic material that the virus can inject
into vulnerable cells to infect them. So-called spike proteins
extend from within the core to the viral surface and allow
the virus to "recognize and latch onto" . When the spike
engages its receptor [on a host cell], a cascade is triggered,
resulting in the merger of the virus with the cell. This merger
allows the virus to release its genetic material and hijack the
cell's internal machinery. Once this happens, the virus sheds
its coat and turns the cell into a factory that starts churning
out new viruses.
Signs and Symptoms
People with COVID-19 have had a wide range of symptoms
ranging from mild symptoms to severe illness. Symptoms
may appear 2-14 days after exposure to the virus. People
with these symptoms may have COVID-19:
● Fever or chills
● Cough
● Shortness of breath or difficulty breathing
● Fatigue
● Muscle or body aches
● Headache
● New loss of taste or smell
● Sore throat
● Congestion or runny nose
● Nausea or vomiting
● Diarrhea
Mode of Transmission
The virus can spread from an infected person’s mouth or
nose in small liquid particles when they cough, sneeze,
speak, sing or breathe heavily. These liquid particles are
different sizes, ranging from larger ‘respiratory droplets’ to
smaller ‘aerosols’.
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Other people can catch COVID-19 when the virus gets into ● Dentists should minimize the use of ultrasonic
their mouth, nose or eyes, which is more likely to happen instruments, high-speed handpieces, and
when people are in direct or close contact (less than 1 metre 3-way syringes to reduce the risk of generating
apart) with an infected person. contaminated aerosols
● Provision of negative-pressure treatment
Current evidence suggests that the main way the virus rooms/airborne infection isolation rooms
spreads is by respiratory droplets among people who are in (AIIRs)
close contact with each other.

Aerosol transmission through aerosol generating

procedures can occur in specific settings, particularly in
indoor, crowded and inadequately ventilated spaces, where
infected person(s) spend long periods of time with others,
such as restaurants, choir practices, fitness classes,
nightclubs, offices and/or places of worship.

The virus can also spread after infected people sneeze,

cough on, or touch surfaces, or objects, such as tables,
doorknobs and handrails. Other people may become
infected by touching these contaminated surfaces, then
touching their eyes, noses or mouths without having cleaned
their hands first.

COVID 19 and Dentistry

Dentistry is one of the most exposed and affected

profession the Covid 19 contagion has brought. During the
height of pandemic, dental procedures across the world
were halted as dental professionals are identified being at
high risk for nosocomial infection and can become potential
carriers of the disease. Posted in several studies, the risks
can be attributed to the unique nature of dental
interventions, which include aerosol generation, handling of
sharps, and proximity of the provider to the patient’s
oropharyngeal region. The dental office has also the
potential to expose patients to cross contamination if not
well equipped with infection control measures and dental
health professionals not knowledgeable in the safety
precautions.

Telescreening and triaging is the initial measure of

precaution to assess the urgency of the illnesses and injuries
prior to consultation. Patient's evaluation and cohorting is
done by the dental staff during appointed time though
medical history and emergency questionnaire. Patient's
body temperature is also assessed.

Specific dental infection control measures recommended

and as follows:

● Dentists should follow standard, contact, and

airborne precautions including the appropriate
use of personal protective equipment and
hand hygiene practices
● Preprocedural mouth rinse
● Use of disposable (single-use) devices
● Dentists should use a rubber dam to minimize
splatter generation

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