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Acknowledgement & Dedication

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Table of Content

Code Title Page

Acknowledge II

Table of content III

List of tables IV

Abstract 1
1 CHAPTER ONE: INTRODUCTION 2
Introduction 2

Aim of the study 2

Materials and methods 2

2 CHAPTER TWO: LITERATURE REVIEW 4

Contamination prevention 4
Disinfection products selection 4

Dental clinics 5

Dental laboratories

Dentures

Possible risk of transmission of COVID-19 in dentistry

Special precautions in dental procedure

3 CHAPTER THREE: FINDINGS AND DISCUSSION 9

Findings 9

Discussion 16

4 CHAPTER FIVE: CONCLUSION AND RECOMMENDATIONS 19

Conclusion and Recommendations 19

REFERENCES 20

Figure 1 9

Figure 2 9

Figure 3 10

Figure 4 10

Figure 5 11

Figure 6 11

Figure 7 12

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Figure 8 12

Figure 9 12

Figure 10 13

Figure 11 13

Figure 12 13

Figure 13 14

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ABSTRACT

The aim of this study was to measure infection control measures and practice among dental laboratory and

clinics experts within the city of Sabratah and Surman In Libya. Twenty dental experts participated during this

study. Data were collected by means of a questionnaire. The questionnaire involved questions about cross

contamination infection control protocols practiced among dental laboratory and clinics experts within the city

of Sabratah and Surman in Libya. A complete of twenty laboratory experts participated within the

questionnaire. The findings showed that 55% of dental technicians were intimate proper infection control

protocols. the bulk of dental technicians demonstrated compliance with standard personal infection control

protocols. Additional compliance with infection control protocols is mandatory among dental laboratory

experts.

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CHAPTER I
INTRODUCTION

Introduction

The dental healthcare professionals, including laboratory personnel, are always facing the threat of infection

transmission. Therefore, as members of the healthcare profession, it is recommended that we guarantee a safe

working environment to stop the danger of transmission of infection during various stages of dental treatment.

to make sure of that, the utmost infection control procedures are being applied in dental operatory (1,2).

Most of dental laboratories do not have any plans to control or prevent infection which could be due to the

carelessness or the absence of qualified experts. Furthermore, the dental experts are in danger by this infection

while they are contributing in treating of patients. The construction of prosthesis for communicable disease

carriers presents a cross contamination hazard. Dentures, crowns, bridges, impressions, casts and other saliva

or blood coated items are all exposed to contamination within the patient’s mouth. Such objects can spread

infectious agents to similar objects within the laboratory, where technicians and other patients are susceptible

to exposure (3,4).

As regard of the danger of infection of dental healthcare workers and patients, interruption of possible chains

of infection, applied infectious control programs should be demanded.

Media publicity has increased public awareness of the necessity for adequate and obvious nonsocial infection

control within the dentistry. Patients now expect and demand high standards of care albeit their knowledge of

aspects of nonsocial infection control is restricted.

As members of the healthcare profession, it is recommended that we ensure a safe working environment to

stop the danger of transmission of blood-borne viruses and other infectious agents not only from patient to

dentist but also from dentist to patient. to make sure a maximum infection control procedure, many of

protocols were involved to satisfy standardize universal precaution. However, people always trying to find

more protective and efficient precautions (5,6,7).

Aim of the Study

The aim of this study was to measure infection control procedures and practice among dental laboratory

technicians within the city of Sabratah and Surman in Libya.

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Materials and Methods

Data were gathered from dental laboratory technicians in response to a questionnaire developed by the

authors. a complete of twenty dental technicians participated within the questionnaire that was distributed at a

university-based, also as, commercial dental laboratories and clinics, within the city of Sabratah and Surman.

Feedbacks from dental technicians were collected. The questionnaire included inquiries about their practice of

infection control measures. Participants were asked about their prior infection control education. Participants

were also questioned about their hand sanitization protocol and their use of private protective equipment.

additionally, the questionnaire included questions on the utilization of disinfectant solution and therefore the

protocol wants to sanitize dental impressions and polishing tools. Descriptive statistical approach was wont to

analyze the data. distribution tables were formulated from participants’ responses.

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CHAPTER II

LITERATURE REVIEW

Contamination prevention

Preventing the spread of infection is a constant duty for dental teams since the risk of cross-contamination

begins when the first patient walks through the front door and continues throughout the day, impacting every

surface from the pen in the waiting room to the dental chair in the operatory.

Routine and complete surface cleaning and disinfection are vital, especially with the impressive survival rates

of potentially harmful pathogens on high-touch surfaces present in dental facilities. Influenza viruses can

survive on hard surfaces for up to 48 hours, while viral particles of the highly-contagious norovirus can live on

surfaces for days, and those of methicillin-resistant Staphylococcus aureus (MRSA) can even survive on

surfaces anywhere from seven days to seven months.1

With almost 80 percent of infectious diseases being spread by touch2, the opportunities for cross-

contamination between the surfaces of the physical environment and the patients and staff interacting with

these settings are boundless. While dental operatories are often thought of as the primary area of concern,

research in dental offices has shown that surfaces inside and outside of the dental operatory can be

contaminated with bacteria. One study found that nearly three-quarters of patient and dentist chairs and a

quarter of reception-area countertops across 11 offices were contaminated with E. coli.3

Disinfection products selection

When selecting a surface disinfectant, look for Environmental Protection Agency (EPA) registered cleaner-

disinfectants that are ready to use and those with short contact times to facilitate faster room turnovers.

Products that allow for one-step cleaning and disinfection, such as Clorox Healthcare® Hydrogen Peroxide

Cleaner Disinfectants, which have 30 seconds to one-minute disinfection contact times on most bacteria and

viruses, and have been shown to effectively reduce bacteria commonly found in dental offices, including

MRSA3, ensure greater compliance from users and save teams time and energy without sacrificing efficacy.

Dental facilities also frequently face the costly tradeoff between efficacy and surface compatibility when it

comes to selecting surface disinfectants. Frequent use of incompatible disinfectants on surfaces could lead to

equipment and surface damage, impacting esthetics and even forcing facilities to purchase replacements.
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Identifying the surface materials present in the facility and contacting the manufacturers directly to determine

which disinfectants are compatible are key steps in ensuring the selected disinfecting products are surface

compatible. Healthcare disinfectants such as the Clorox Healthcare® Fuzion™ Cleaner Disinfectant aim to help

eliminate this problem, offering broad surface compatibility with the plastics and stainless steel, among other

materials, commonly found in dental facilities.

Cleaning and disinfection happen throughout the entire facility - from the reception area to the operatory to the

instrument reprocessing areas. It’s important to educate all staff involved in the cleaning and disinfection

process on how and where to use each product. Secondly, teach team members how to navigate product labels

that contain safety information, directions for use, disinfection claims and contact times, key surfaces and use

sites, and storage instructions.

To ensure all team members are properly equipped with the right materials and the knowledge to help protect

patients and staff from these infectious diseases, be sure to regularly review regulations and infection control

guidelines. Educate the team on the Occupational Safety and Health Administration (OSHA) Bloodborne

Pathogens Standard and the Centers for Disease Control and Prevention (CDC) Infection Prevention Checklist

for Dental Settings. Establish clear roles and responsibilities and review the basics of proper hand hygiene in

the effort to build a robust infection control protocol.

Remember, if not implemented correctly, even the best products and protocols will not be effective against the

harmful pathogens, bacteria and viruses that lurk on the high-touch surfaces of waiting and treatment rooms.

Dental facilities should also consider investing in continuing education (CE) training through sites like Viva

Learning, which offer CE courses for free. Teams should also regularly refer to the resources offered by

OSHA and the CDC for the most up-to-date infection prevention and control guidelines and resources for

dental settings.

Dental Clinics

All clinical materials sent to dental laboratories must be cleaned and disinfected at the dental office before

sending to the laboratory. If there's no clear identification of the completeness of the disinfection procedures,

all received clinical materials must be disinfected at the dental laboratory. One key element within the cross

contamination within the dental field is that the dental impression. Contaminated dental impression

contaminates the dental cast also. There are many citations regarding the transfer of microorganisms to the

dental impressions and consequently to the dental casts. Transferred microorganisms may remain viable for up

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to 7 days. due to possible damage to the dental cast, it's recommended to disinfect the dental impression before

pouring casts [3]. A chemical disinfectant that's compatible with the dental impression material must be used

in order that it doesn't alter the dimensional accuracy or surface texture. After washing the impression under

running water, the impression could also be disinfected by spraying or immersing. The spraying technique

utilizes less quantity of the disinfectant solution. However, it's likely to end in incomplete coverage of all

impression surfaces, undercuts especially, and also release chemicals into the air. In contrast, the immersion

technique, involves complete coverage of the impression within the disinfectant [3]. Thereby, the dipping

technique is simpler and has less potential for occupational exposures. the foremost common disinfectants

solutions and sprays include: 5.25% hypochlorite, 7.5% peroxide, and dioxide. The disinfectant solution must

be tuberculocidal and supply a TB wait on the labeling. The hydrophilicity of those materials with reference to

tolerance to immersion in fluids may be a significant think about the disinfection protocols for impression

materials. Thereby, the manufacturer’s instructions for disinfection must be followed.

Dental Laboratories

Hand sanitation during a dental laboratory is preformed through washing with soap and water. Waterless

alcohol-based hand rubs can also be used. Installing automatic hand-sanitation dispensers could also be

considered for simple use, also as, to encourage frequent use [4].

Special protecting gear including heavy gloves and facemasks must be utilized whenever there's a probable

risk of cross-contamination. Also, allocated receiving, production, and distribution areas offer organized

implementation of an effective infection control plan. The receiving area handles all incoming items. At the

receiving area, all items must be cleaned and disinfected. This area must include running water and hand-

washing facilities. within the production area, no contaminated items are allowed. The shipping area is where

articles departing the dental laboratory takes place. within the shipping area, all case containers must be

cleaned before using for subsequent case.

Special precautions must be taken when performing procedures with potential cross-contamination. Protective

safety glasses must be worn when using dental lathe. Adding a disinfectant agent to pumice is suggested to

attenuate cross-contamination. Regular washing and sterilization of finishing and polishing lath, brushes, rag

wheels, and other laboratory tools are essential.

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Dentures

Dentures are usually covered with saliva, gingival fluid, and bacterial infection. All body fluids are

contaminated with opportunistic pathogenic microorganisms. Consequently, the denture might become a

source of cross-contamination infection between patient, dentist and dental laboratory technician.

Contaminated prostheses must be disinfected before sending to the dental laboratory. The prosthesis must be

cleaned employing a brush and an antimicrobial soap to eliminate debris. just in case of presence of adherent

calculus to the prosthesis; the prosthesis must be sealed in bag containing an ultrasonic cleaning solution or

calculus remover, then placed within the ultrasonic cleansing machine [4]. The ultrasonic machine should be

covered to avoid splatter. this is often followed by, cleaning with a detergent, rinsing, and drying before

performing any laboratory work on the prosthesis.

Possible risk of transmission of COVID-19 in dentistry

While it may be difficult to identify the particular mechanism of infection for individual patients, we are

aware of the common routes of transmission. Droplet transmission and transmission through fomites (objects

or materials which are likely to carry infection) are the main modes of transmission by the respiratory system

in intrapersonal contact and especially during sneezing, dry coughing, or even talking [5]. Eye exposure has

also been reported as a route of transmission for the virus, with infectivity even higher than that of SARS [5].

We also know that COVID-19 is present in saliva, but transmission through this route has not been

conclusively confirmed [8]. Considering the main path of transmission of the COVID-19 disease, dental

procedures that lead to the spray of saliva particles into the air (which means almost all dental procedures)

could heighten the possibility of contamination [6]. Much effort has been made in the literature to define

droplets and aerosols and to distinguish between their ability to carry the COVID-19 virus. Knowing which

dental procedures produce aerosols that could carry the virus is important to help define the level of risk that

these procedures create. This then helps to define what Personal protective equipment (PPE) is appropriate. As

a result, both kinds of particles, or better to say, anything that comes out of the patient should be considered

hazardous [9]. Given the fact that the majority of dental instruments are made from metal and polymers, the

COVID-19 could adhere and persist on these surfaces for several days. Consequently, they could present a risk

of virus transmission if they are not adequately decontaminated [6]. Fundamentally, COVID-19 in dentistry

may be transmitted through air, droplets, and contact [8]. Not only could the professionals act as transmitters,

but also, they could become infected during human-to-human transmission, through non-invasive salivary

secretions like a patient’s cough or sneeze, or treatment procedures, such as using a high-speed handpiece or

ultrasonic instruments which release aerosols which may contain saliva or blood bacteria and viruses into the
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environment. Therefore, using appropriate protective wearing is critical, given the fact that the spreading of

saliva and dental fluids has the potential of virus transmission because of the close distance between patients

and professionals [7].

Special precautions in dental procedure

PPE and hand hygiene should be given very serious attention in a dental clinic at all times, even when no

patient is present [7]. Regular hand hygiene could be regarded as a critical element in any controlling protocol

to reduce the outbreak of infection [8]. Due to the fact that dentists have close contact with the patients and

their hands are exposed to the mouth fluids and aerosols, using an antiseptic solution before treatment of each

patient is of the utmost importance. Although broad types of antiseptic solutions are available, the ethanolic

solutions (above 70% concentration) are suitable for this process because of the non-toxic entity, while

ethanolic solutions are useful in hand hygiene; using soap and water is also effective [9]. Using masks with

pores of less than 50 μm is necessary for dental professionals [9]. On the other hand, these particles could be

transmitted through the eyes; therefore, using appropriate goggles or face shields could decrease the risk of the

infections [9].

As the aerosols spread from the mouth, suggesting to patients, they use an antiseptic oxidative mouth rinse

would be protective prior to and after treatment. Currently, ADA and CDC only recommend peroxide to

eradicate the virus. Moreover, public health authorities have advised 0.2% chlorhexidine mouth-wash (CHX),

1% povidone-iodine (P.I.), 1.5% hydrogen peroxide (H2O2), or 0.05% hypochlorous acid (HOCl). CHX is

weak in terms of viricidal, and the other three (P.I., H2O2, HOCl) all have excellent viricidal properties but

are weak in substantivity, because saliva flow can potentially replace the virus. Clinically, the most acceptable

in terms of viricidal and taste is 1.5% hydrogen peroxide [9].

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CHAPTER III

FINDINGS AND DISCUSSION

Findings

Twenty dental technicians with a professional experience ranging from 3 to 14 years have participated in

the survey. The twenty male and one female specialist were coming from five dental laboratories in the

cities of Sabratah and Surman. Fourteen participants were affiliated to university governmental institution

and twelve were affiliated to the private sector (Figure 1). Responses to survey questions are summarized in

figures 1 through 14. Majority of technicians (61.5%) reported receiving infection control training courses

(Figure 2). Fifty percent of participating technicians reported not having infection control manual in their

laboratories, whereas, 42.3% reported the presence of such a manual (Figure 3). More than one half of

included technicians (57.7%) reported the absence of any infection control leaflets mounted in the

laboratories and only 30.7% of them reported the presence of instruction leaflets (Figure 4). Washing with

soap and water was the most common cleaning/disinfecting protocol used in the dental laboratories. It is

used by 73% of technicians to clean their hands, most commonly in-between cases (Figure 5), by 50% of

technicians to clean brushes of lathe cut machines (Figure 6) and by 53.8% of technicians to clean rag

wheels of lathe cut machines (Figure 7). Sixty five percent of all technicians use more than one method in

cleaning their hands (Figure 5). Figures 6 and 7 demonstrate methods utilized by dental technicians to clean

and/or disinfect or sterilize bushes and rag wheels used in the lathe cut. Only one technician reported using

more than one method in cleaning lathe cut brushes (Figures 7) and only two technicians practice more than

one method in cleaning lathe cut brushes and rag wheels (Figures 6). Changing the pumice solution used in

the lathe-cut machine was reported by only 26.9% of dental technicians (Figure 8). The most com- mon

protective items worn by dental technicians while working were gloves followed by protective eyewear,

with about 76.9% of technicians wearing more than one protective item (Figure 9). 30.7% of technicians

were able to identify sodium hypochlorite solution as the disinfectant solution used in their laboratories,

whereas 27% of all technicians were unaware of the type of disinfectant solution in-use (Figure 10). Dental

impressions were the most common items to be disinfected by 73% of all technicians (Figure 11). Most of

the technicians (38.5%) reported occasional reception of dental impressions containing saliva debris from

their dentists (Figure 12). Ninety-two percent of the technicians wash the received dental impressions under

running water (Figure 13) and 76.9% disinfect the impressions prior to handling (Figure 1).

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Figure 1: Number of participating dental technicians belonging to governmental institution and private sector.

Figure 2: Number of dental technicians who received training courses on infection control protocols.

Figure 3: Number of dental technicians reporting on the presence of infection control manual in their laboratory.

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Figure 4: Number of dental technicians reporting on the presence of infection control instruction leaflets in their
laboratory.

Figure 5: Number of dental technicians using different hand sanitization protocols in their laboratories.
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Figure 6: Number of dental technicians reporting on the method of cleaning brushes used in the lathe cut machine in their laboratory.

Figure 7: Number of dental technicians reporting on the method of cleaning rag wheels used in the lathe cut machine in their laboratory.

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Figure 8: Number of dental technicians reporting on the frequency of changing pumice solution used in the lathe cut machine.

Figure 9: Number of dental technicians using different types of protective equipments in their laboratory.

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Figure 10: Number of dental technicians using different types of disinfectant solution in their laboratory.

Figure 11: Number of dental technicians reporting on the type of items disinfected in their laboratory.

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Figure 12: Number of dental technicians reporting on the frequency of receiving impressions containing saliva debris from their dentists.

Figure 13: Number of dental technicians reporting on washing dental impression under running water prior to handling.

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Figure 14: Number of dental technicians reporting on disinfecting dental impressions prior to handling.

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Discussion

Possible routes of cross contamination include direct and/or indirect cross-contamination. Direct contact

with contaminated saliva or blood occurs through skin abrasions. An important potential cross-

contamination risk for dental laboratory technician is through indirect contact [4]. Indirect cross-

contamination infection may occur through airborne microbial aerosols splatter during laboratory

procedures.

Powell., et al. [5] emphasized the importance of adequate infection control procedures to prevent possible

cross-contamination. The recommendation was based on their findings, which revealed a 76%

contamination of materials received from dental clinics to dental laboratories in four cities. The most

frequently recognized microorganisms were Streptococcus, Staphylococcus, Escherichia coli, Actinomyces

species, Antitragus species, Pseudomonas species, Enterobacter species, Klebsiella pneumonia and

Candida species [6]. Taking this into account, efforts must be made to eliminate these microorganisms and

decrease the frequency of cross contamination infection in dental laboratories.

This survey evaluated infection control measures and practice among dental technicians in the cities of

Sabratah and Surman in Libya. In the present study 61.5% of dental technicians were knowledgeable about

proper infection control protocols. The majority of dental technicians demonstrated compliance with

standard personal infection control protocols. Hand washing supplemented with alcohol disinfection was

reported by 69% of the technicians. 80% and 76.9% of the dental technicians demonstrated the wear of

gloves and protective eyewear, respectively.

A study by Mary., et al. [7] at the dental colleges in Karachi evaluated the attitude of dentists in Karachi

towards the disinfection of dental impression. The results of the survey revealed that only 29% of the dental

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practitioners did utilize a disinfect solution to disinfect the dental impressions. 58.5% of practitioners did

not utilize any disinfectant solution to disinfect the impression and 15.6% did not rinse their dental

impressions after they are made. Unavailability of disinfectant solutions in clinical practices and lack of

awareness of the importance of the issue, were among the most common reasons of their disregard. 14.7%

of dental practitioners considered disinfecting the dental impression is time consuming and unnecessary

process. 9.9% of practitioners reported that disinfection of impression is not necessary, as it has to be

poured. 13.4% of the dentists did not purchase the disinfectants, as they are expensive. Only very few

dentists believed that the disinfectant solution might result in corrosion of metallic impression trays. 13.5%

were also concerned about dimensional instability of the dental impression material.

In contrast to the Mary., et al. [7] study which focused on cross-infection prevention protocols by

dentists, our study focused on the role of the dental technician to prevent cross-contamination. As stated

earlier, unless there is clear understanding between the treating dentist and the dental technician regarding

the disinfection of the dental impression or the dental prostheses, the dental technician must disinfect

received dental impression and prostheses prior to handling. Marya., et al. study indicated that 15.6% of

dentists do not rinse the dental impression after they are made. In contrast, our study indicated that 38.5% of

the dental technicians reported occasional reception of dental impressions containing salivary debris.

Nevertheless, the potential hazards associated such a violation of infection control standards via transporting

contaminated dental impression seem to have been minimized by the fact that in this study dental

impressions were the most commonly disinfected items as reported by 73% of the dental technicians.

Jagger., et al. [8] surveyed cross-infection control in registered dental laboratories. 49% of participants

had a cross-infection policy. 30% of laboratories receive identified un-disinfected matters from the dental

clinics. 44% of the respondents reported wearing gloves when handling received dental items. 74% reported

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wearing protective eye shield during trimming and/or polishing dental prostheses. 51% reported disinfecting

received dentures. 61% no disinfectant solution was mixed with the pumice and 93% did not disinfect the

polishing tools. In contrast in our study, 34.6% of the dental technicians reported disinfecting received

dentures, and 7.7% of the dental technicians reported disinfecting finishing and polishing laboratory brushes

and rag wheels. The reported ratio of disinfecting denture in this study is less than that reported by Jagger.,

et al [8].

Wakefield [9] evaluated laboratory potential pathogenic microbiologic cross-contamination of dental

prostheses through the dental laboratory. The study reported receiving 9 contaminated complete dentures

out of 10 sterile one that were sent to dental laboratories for repair. The author assumed possible

pathological microbial attribution from other patients. Agostinho., et al. [10] evaluated microbial

contamination in the dental laboratory throughout the polishing process of complete dentures. The authors

reported a significant microbial splatter and aerosols contamination during the polishing process using high-

speed lathes. The polishing cones were highly contaminated after polishing, which resulted in transfer

microorganisms from the infected spindle to the sterile dental prostheses. Molinari., et al. [11] emphasized

that the cones used for polishing must be sterilized after each polishing procedure.

Dental pumice used in conjunction with finishing and polishing brushes and rag wheels is another dental

potential source of cross- contamination through the dental laboratory. Williams., et al. [12] Cultural studies

demonstrated contamination of laboratory dental pumice with high numbers Acinetobacter, implicated as

opportunistic pathogens. In addition, fungal colonies disclosed from 10 pumice samples in two dental

laboratories [13]. In our study, changing the pumice solution was only reported by 26.9% of the dental

technicians.
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This study highlighted several potential sources of cross-contamination in the dental laboratory, which

were proven to be highly infectious, yet this study demonstrated low compliance rate - in these areas- with

infection control protocols recommended. Thereby, emphasis must be reinforced that dental items must be

disinfected in the dental clinic before they are sent to the laboratory and upon receiving the items from the

laboratory as well.

Prevention of infection through cross contamination in the dental environment is an integrated work.

Despite literature evidence, infection control guidelines and recommendations; however, the question

remains why dentists don’t disinfect their sent items and why the dental technicians are not strictly adherent

to these cross-contamination infection control protocols?

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Chapter V

CONCLUSION AND RECOMMENDATIONS

Conclusions and Recommendations

Cross-contamination among dental team personals is a hazardous concern. More efforts must

be made to avoid such a hazardous situation. Strict compliance with infection control protocols

is mandatory in the dental clinics, as well as, in dental laboratories.

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