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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Digital Esthetics. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
Why minimizing infection risk is vital to you, your practice and your patients.
Everyone knows how important good infection control can be. And while it’s accepted as a fact, the truth of the matter is many practices are putting themselves at substantial risk by letting things fall through the cracks. Some oversights are very subtle and easy to overlook, while others are glaringly obvious. We talked to some experts in the field of infection control to discuss some of the ways that your practice may be at significant risk of infection.
The biggest way infections happen is when healthcare professionals aren’t paying attention to detail. This can lead to contaminations in one area spreading to another.
“Working around and with blood and other body fluids just seems to become routine; therefore, staff and dentists can become unaware of how they are cross contaminating in operatories and other areas of the practice,” says Mary Borg-Bartlett, president of SafeLink Consulting.
And while some infection control measures are standard and should be learned in school, there are others that are likely unique to the practice. For instance, specific pieces of equipment must be maintained in a unique way. Those distinct procedures must be clearly disseminated to staff.
“Following the practice’s infection control procedures is critical in order to avoid cross-contamination of work surfaces, equipment, personal protective equipment and instruments,” Borg-Bartlett says. “An example is wearing personal protective clothing outside the operatory after treatment that has created spray or spatter. Gowns and lab-type coats should be removed in the operatory and not worn into other parts of the practice.”
Another of the most common sources of infection is also the easiest to correct - adequate hand hygiene.
“Proper hand hygiene is the simplest thing we can do to prevent the spread of infection,” says Karen Daw of Karen Daw Consulting and former clinic health and safety director for The Ohio State University College of Dentistry. “Yet many people are not aware of recommendations for when and how to perform hand asepsis properly. Most people know to wash hands between patients, but I see many skip hand washing when touching objects likely contaminated by blood or saliva. And washing hands after glove use protects the provider in the event the gloves have become perforated. This type of breach can allow bacteria to make contact with the skin.
“For most procedures, a vigorous scrub with soap and water will work just fine (the scrub creates friction),” Daw adds. “Be sure to scrub vigorously for at least 20 seconds. Ask how long that is equivalent to and most people will correctly answer: singing ‘Happy Birthday’ to yourself twice or the ABCs once, slowly. And so long as the hands are not visibly soiled or contaminated, an alcohol-based hand rub is adequate between patients and glove change instead of soap and water.”
It might be easy to get lulled into a false sense of security when wearing gloves. But even if wearing gloves, it’s still necessary to wash your hands. While gloves seem like they should provide an impenetrable barrier against infection, the fact is that they don’t. As such, hand hygiene remains critical.
“Hands should be washed prior to gloving and immediately after removing gloves,” Borg-Bartlett says. “In most cases, workers wash their hands upon removing gloves; however, prior to donning gloves, they don’t. The issue here is that gloves are not 100-percent perfect and contain microscopic imperfections. If a worker doesn’t have clean hands prior to gloving, then germs on the hands can make their way through the gloves. This works the other way also. Microbes can enter imperfections in the glove, which requires hand washing immediately after removing gloves.”
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Expanded specialty practice
As new caries rates fall, dentists may be looking for specialty services to generate additional practice income. Boomer generation patients need more complex procedures, including implants, but some doctors may find that they’re biting off more than they can chew when it comes to risk management.
“More general dentists are going into areas that are actually oral surgery, such as implants or periodontal treatment,” says Peggy Spitzer, a dental hygienist and clinical education manager for Certol International. “And that may be their biggest risk when it comes to infection prevention. When they provide more advanced services, they may not be prepared for the infection control standards that come with those procedures. As dentistry becomes more invasive, we are passing the barrier that dentistry relied on for years.”
The Centers for Disease Control and Prevention defines oral surgical procedures as the incision or reflection of tissue and bone exposing normally sterile areas of the body.
“I’m sorry to say that some are putting themselves at risk because even though they may have wonderful technique and well-trained staff, they have not thought about how they’re doing their infection control,” Spitzer says. “Also, in some cases, a seemingly simple procedure suddenly becomes much more complex.”
Spitzer says that while those dentists may have the knowledge, skill and staff to handle such procedures, they may not be as prepared as they need to be. For instance, she refers to some third molar extractions.
“A lot of dentists refer out third molar extractions because third molars are tricky,” Spitzer explains. “They start out looking like they’re going to be routine, but then suddenly it’s a bony impaction and they’re performing oral surgery in the midst of what started out as a routine procedure. Then they don’t have the conditions set up that they need to have to perform oral surgery.”
In order to be prepared for those conditions, doctors should have sterile gloves, sterile water delivery and a surgical-grade hand scrub - all outlined by the CDC. But in the face of changing circumstances, the doctor must be prepared.
“The dentist may have sterile gloves, but they also need to keep up inventory in sizes for the assistants,” Spitzer says. “Everybody who is in that procedure needs to have sterile gloves. And if their instrument processing is not consistent, they may have contaminated instruments in the pack. They have sterilized it, but if the instruments were never cleaned properly, now there could be contamination in the surgical site.”
Improper personal protective equipment use
Personal protective equipment (PPE) is certainly necessary and something any practice would have on hand, but it’s not enough simply to have it - it must be worn correctly.
“During any patient treatment where there can be spray or spatter, they should leave that personal protective equipment at the site and not take it home to launder,” Borg-Bartlett says. “It should be changed between patients whenever there is spray or spatter. If a patient is there just having a hygiene appointment, that hygienist would need to wear PPE over their clothing and remove it after treatment of that patient and put on fresh PPE for the next patient. If the dentist is coming in just to do a quick look and exam of that patient after the hygiene appointment, they wouldn’t have to change it between patients, unless they were with another patient and had spray or spatter on their PPE. The key to it is spray or spatter and not to move the spray or spatter out of the operatory.”
PPE problems can involve things as unassuming as a face mask.
“I have seen clinical personnel in non-clinical areas (reception area, lunch room, etc.) wearing their mask pulled below their chin,” says Dr. Marie Fluent, DDS, an educational consultant for The Organization for Safety, Asepsis and Prevention (OSAP). “When I see this, I don’t know if the mask is contaminated or not, nor if they’ve changed it in between patients nor if they intend to perform a clinical function wearing the mask in this fashion. Masks are intended to cover the nose and mouth and form a complete seal. Masks are single-use and they should be removed and disposed of immediately after the dental procedure.”
While the process of wearing appropriate and non-contaminated PPE may seem be cumbersome and difficult, it’s necessary to avoid cross-contamination.
“It is a challenge for the dentist,” Borg-Bartlett says. “But we do have dentists who use disposables and have become proficient in handling it when treating more than one patient at a time. They simply remove the PPE and leave it in that operatory before moving to the next operatory. In other words, they should not be moving between operatories with the same personal protective equipment when there is spray or spatter on the PPE. This is one of the major issues that we see involving cross-contamination, plus one that I have seen OSHA issue citations for in dental practices.”
Not following strict sterilization protocols
The instruments used on patients must, obviously, be cleaned and sterilized. However, too often those procedures aren’t followed appropriately. Sterilizers are a necessary fixture in any dental practice. But unless instructions and procedures are followed precisely, the instruments may not be adequately processed and pose an infection risk.
“The CDC publishes very clear guidelines for sterilization of instruments plus monitoring practices to be followed to ensure the sterilization equipment is functioning properly,” Borg-Bartlett says. “Some examples are when staff is in a hurry to remove instruments from the autoclave before the drying process has been accomplished, this compromises the sterility of the instruments, plus it can result in rusting or corrosion of instruments. It’s not uncommon to see moisture in packets or packets where it’s apparent that the moisture has dried after removal from the autoclave. Also, overloading the autoclave is an issue that can also cause moisture in the packets. Another issue is ignoring failure reports and continuing to use the autoclave. When a failure report is received, the autoclave should be taken out of service until it can be serviced and testing performed to see that it’s in good working order.”
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Failure to audit or monitor the infection control practices frequently
One may think that his or her infection control policies and practices are effective because staff members do, in fact, follow them conscientiously. However, it’s important to ensure that the policies and procedures being followed are correct and that they’re working. To ensure that the office’s efforts are getting the job done, it’s necessary to audit and monitor those practices. It’s not only a good idea - it’s also a mandate.
“OSHA requires an annual review of the Exposure Control Plan, which is the program that defines how the practice is going to protect its workers from exposure to potentially infectious items,” Borg-Bartlett explains. “In the last CDC recommendations for dentistry, the CDC recommended that an infection prevention coordinator be appointed. The responsibility of this coordinator would be to perform periodic audits or surveys of the infection control or prevention practices and bring to the dentist’s and staff’s attention where the breakdown is occurring so that they can be corrected right away.”
Clinicians also need to be aware of more than just their local environment when considering infection control. More and more immunocompromised patients are coming into practices - who may have a health condition that the care team needs to know about.
“Our patients are coming to us more vulnerable,” Spitzer says. “They are immunocompromised, and we didn’t have that even five or 10 years ago. People did not come to the dentist right after cancer treatment. And now, they are well enough and ambulatory, even though they’re going through all these serious health conditions. The thing that dentistry has relied on for so long was a perception of ‘Oh, there’s not really all that much risk.’”
No matter what condition a patient is in, he or she may still require dental care, whether it be an emergency or just a routine visit.
“Maybe they’ve just finished chemo, but they need to go see the dentist - and it doesn’t need to be a major invasive procedure; maybe it’s routine recare and cleaning,” Spitzer says. “If they have a really low white blood cell count, then that could put them at risk.”
Clinicians may not know that patients are at risk, but it’s up to them to find out. That’s all the more reason why clinicians must take a thorough health history - even for a routine visit.
“Every dentist, including general dentists, need to make sure they have a really robust health history review,” Spitzer says. “Listen to people. Sometimes I think these things are so rushed that they don’t really give the patient the opportunity, or they don’t prompt them thoroughly enough. Ask questions and really listen to the answers.
“And, of course, it’s a visual thing, too,” she continues. “Are they paying attention to physical signs? Do they look anemic? Do they have yellow eyes? There are physical signs that everyone learns in dental school. Patients may not understand what the dentist needs to know about their health or medical treatment. Also, patients tend to chat more with the staff. Dentists can train staff to be alert for comments about health or basic physical signs and symptoms, all of which should be reported to the dentist.”
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How instruments are cleaned and sterilized is a common source of infection control problems. Too often, inadequately processed instruments can lead to big problems.
“In fact, many of the infection control breaches that seem to make it into the news involve unsterilized instruments,” Daw says. “And yet, so few are aware of all the steps to follow from the moment dirty instruments arrive in this area to the moment the instruments are used on the patient after being retrieved from a successful sterilization cycle.”
The proper process is seemingly straightforward, but too often it’s misunderstood.
“This could be a day-long class in itself, so I’ll just share that some of the more common observations,” Daw says. “This first is lack of a proper flow in the sterilization area from the ‘dirty’ side to the ‘clean’ side. Also, not having distinctive areas within the sterilization area to prevent doubling back or potential cross-contamination. The CDC lists four major areas that an instrument will travel through from dirty to clean: 1. Receiving, cleaning and decontamination; 2. Preparation and packaging; 3. Sterilization; and 4. Storage. Ideally, there will be plenty of space to facilitate the one-directional flow.”
In addition to the standard processng workflow laid out by the CDC, it’s likely that specific instruments or pieces of equipment will require specialized care and attention.
“Another major risk is not following the manufacturer’s instructions on reprocessing,” Daw adds. “For example, the IFU, or Instructions for Use, on some handpieces state to clean, lubricate and then sterilize the handpiece and motors between patients. And yet, some offices are merely wiping them down with disinfectant. The CDC even listed in their 2016 Summary that handpieces and motors that can be detached from air/water lines should be reprocessed according to manufacturer’s instructions.”
Nothing is too minor or obscure when it comes to infection prevention. In addition to the obvious sources of potential problems - like hands, instruments and equipment - even the surfaces in an operatory require attention.
“Clinical surface areas, or those areas that are at high risk for contamination, should be cleaned and disinfected between patients,” Daw says. “Even with barriers, these surfaces should be disinfected if the surface becomes contaminated during the process of removing the barriers. In addition, surfaces covered by barriers should be disinfected at the end of each work day.”
The products used to clean and disinfect those surfaces must be followed exactly as the label prescribes; otherwise, they will be completely ineffective.
“Some products act as a cleaner and a disinfectant, while others require a separate cleaning step first,” Daw says. “When disinfecting, it’s important to read the labels regarding the pathogens it will inactivate and the contact time necessary to accomplish this.”
It’s easy to fall into a state of apathy when it comes to infection control, but keeping staying informed will help to prevent mishaps.
What’s important, Daw notes, is having written policies and procedures in place.
“It comes into play when you’re onboarding new people,” she says. “You can refer to it, and you can use it for coaching and ongoing internal education.”
And there’s no shame in seeking outside help.
“A lot of the OSHA and infection control coordinators in private practice feel like they have to know it all or the doctor is going to be disappointed,” Daw says. “I don’t think that’s the case. Become a member of OSAP and partner with a consultant so that you have a resource to turn to if you have additional questions.”
Infection control is vital, yet it’s often overlooked - not on purpose, but because there are so many little traps into which a practice can fall. Minimizing infection risk is vital to you, your practice and your patients. Being mindful of the places where infection control is routinely overlooked will keep everyone happy - and safe.