Infection control is an afterthought in the medical community. But in the dental arena, infection control has been in the forefront of discussion and education for the last 3 decades. In my business as a consultant for infection control practices, I have found that most dental offices have a pretty good handle on the basics of infection control. But as with any preventive thought process, the hustle and bustle of everyday life tends to kick infection control to the back burner when the average hygienist or dentist becomes overwhelmed with other duties.
The Role of Education
The first tenet of the best practices of infection control, no matter what profession you are in, is education. A review of prevention practices should be part of the weekly employee meeting. Your office should have a bullet list of important goals that you should touch on at each meeting, including:
- Standard precautions, gloves, and masks (quality and use)
- Hand sanitization
- Water and dental unit cleanliness
- Instrument disinfection and sterilization
- Patient safety
The last bullet point should be an open question to everyone to come up with one concern they have with infection control so you obtain input from every employee. Never assume that all of your employees came to your practice with the same knowledge, as each person has a different educational background. It never surprises me to hear an employee or dentist reiterating myths that have been debunked for decades.
Infection prevention in dental offices can be split into 3 stages. The first is prevention of transmission from the providers to the patient. The second is prevention of transmission from patient to patient. The last is prevention of transmission from the environment, especially water sources, to the patient.
Dental patients and dental healthcare providers can be exposed to bacteria and viruses, including influenza, HIV, hepatitis B and C, cytomegalovirus (CMV), herpes simplex, tuberculosis, staphylococci, and streptococci, as well as myriad other bacteria and viruses that inhabit the mouth. These bacteria and viruses can be transmitted to the patient through direct contact with blood or oral fluids, indirect contact with contaminated objects, or inhalation of microorganisms that can remain suspended in the air for prolonged periods of time. The careful use of standard precautions is instrumental in preventing the transfer of these microorganisms.
Standard precautions have been ubiquitous in dental practices at least since 1990, when a Florida dentist transmitted 6 cases of HIV. Since then, lapses in infection prevention and standard precautions have been unusual in the average dental setting.
Standard precautions require barrier methods when there is an expectation of exposure of the patient or provider to any bodily secretion. Also, hand sanitization needs to be performed before and after each patient contact. Make sure that your hand sanitization dispensers are located in convenient locations. Advancing from this is where education is needed in all dental practices.
Cleaning and Disinfection
Prevention of spread from one patient to another requires a thoughtful approach to what surfaces and instruments need cleaning and disinfecting between patient encounters. It is imperative that the dental chair and the non-disposable parts of the dental unit be cleaned between patients. Or, a paper or plastic barrier needs to be used. Any other surface that is not covered by the paper should be disinfected with either a spray or a disposable wipe that is approved for cleaning these surfaces.
Quaternary ammonium or a hypochlorous solution or other solution that has claims for a less than 10-minute kill time for staph, clostridium, and viruses should be used. These claims should be in the documentation given for the solution. Ultraviolet light cleaning can also be used at the end of the day for what is called terminal cleaning.
The Centers for Disease Control and Prevention classifies instruments and how they are cleaned. Any instruments that come into contact with bone, teeth, gums, or non-intact skin need to be sterilized using steam under pressure, dry heat, or chemical vapor. Before sterilizing, the instruments need to be cleaned to remove any debris. All other instruments that only come into contact with intact skin such as X-ray heads and blood pressure cuffs only need to be cleaned with an intermediate or low-level disinfectant.
These instruments should be stored in a separate clean room. Temperature and humidity control needs to be in place for this room. In addition, inventory control should ensure that a sterile instrument’s shelf life is not exceeded and that instruments sterilized earlier are used first. Packages should be opened in front of the patient, and only someone with clean gloves should handle them prior to opening. After opening, only those with appropriate sterile gloves should be handling the instruments, which need to be placed on a clean, non-contaminated tray.
The Water Unit
The water used for rinsing the patient’s mouth needs to be monitored, as it should be sterile. The use of self-contained water units along with chemical treatment of the water with germicides or the use of inline filters offers the best line of defense against contamination of the dental field.
Because bacteria in the patient’s mouth can contaminate the instrument that discharges the water, this device needs to be flushed for 30 seconds after each patient. Alternatively, disposable tips and expectorators can be used, but flushing should still be performed.
Despite these precautions, there have been reports of localized infection or colonization with Pseudomonas aeruginosa or Mycobacterium species after exposure to water from a dental unit. These pathogens are usually diagnosed in immunocompromised individuals, but there is a definite risk if there is not adequate control of these bacteria. Most bacteria in the lines are not a harm to patients, but these 2 species plus potentially Legionella could be spread to patients.
Lastly, dental healthcare workers should be immune to or vaccinated against hepatitis B, measles, mumps, rubella (MMR), varicella (chicken pox), influenza, and tetanus, diphtheria, and pertussis (Tdap). In addition, dental healthcare workers should not come into work if they are ill. The spread of influenza and other illnesses to their patients is very common for all healthcare providers, and care to not spread these diseases is everyone’s job.
The Organization for Safety, Asepsis and Prevention offers more educational resources about infection prevention at osap.org/page/safestdentalvisit. In addition, the CDC offers a complete discussion of infection prevention at cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm.
Dr. Laartz (drlaartz.com) is a board certified physician in infectious diseases in the Tampa Bay area. He has a consultation practice for infection prevention for the medical and dental fields as well as food handling and processing. He is the author of Protect Yourself: How to Avoid Contagious Diseases, which is geared toward consumers, and the forthcoming Protect Your Patient, which educates healthcare providers in infection control. In addition, he has started a company specializing in manufacturing protective products. He can be reached at (813) 815-0530.