Best Workflows for Infection Control

Best practices for safety for dental practices and patients, especially in light of COVID.

To the lay person, day-to-day operations at the dental practice may have seemed effortless and smooth. That is, dental health care professionals tend to go through their day with a certain aura of élan, but team members would be the first to observe that there is a lot going on behind the scenes to keep everyone safe. And, since the pandemic started, there’s even more to be mindful of, more that is necessary to keep potential infection at bay.

Hierarchy of controls

There isn’t just one thing that practices must do to stay safe. Best practices occur at various stages, as outlined in the National Institute for Occupational Safety and Health (NIOSH) Hierarchy of Controls. Ideally, exposure and risks are mitigated as early in the hierarchy as possible where they are more effectively managed.

That hierarchy is:

  • Elimination
  • Substitution
  • Engineering controls
  • Administrative controls
  • Personal protective equipment (PPE)

“PPE is your last line of defense to anything that you’re exposed to,” Douglas Risk, DDS, says. Dr Risk is the Compliance Manager and private practitioner at Tidewater Dental in Southern Maryland, serves on the Executive Board of Directors for OSAP, is a Diplomate of the American Board of General Dentistry, and is a Fellow of the International College of Dentists. “The concept is that you first try and eliminate a hazard. And then, if you have a hazard that you can’t eliminate, can you substitute something that is less hazardous? For instance, if you can’t eliminate your infected patient with a toothache, then you may be able to medicate that patient instead of seeing them in the office. That would be a substitution, and may be able to buy enough time so that the patient would no longer be infectious.

“You engineer a hazard reduction, then you’re talking about maybe using a rubber dam when you wouldn’t ordinarily,” he continues. “If you have a well-sealed rubber dam, you’re

not going to have leakage. You’re not going to have viruses getting into the operative site.”

Ideally, all of the risks and hazards would be mitigated early in the process. The last line of defense is PPE.

“Once you’ve done everything you can to reduce the risk, then you have to assess the risk,” he observes. “And if you have a significant community viral load, then you’re going to want to have a respiratory protection program. You’re going to want to be wearing an N95 mask. You’re going to want to be throwing away a lot more PPE, because you are generating contaminated aerosols involving much more virus than we had before with the bloodborne pathogens.”

Instrument handling

How practices handle instruments is critical, in light of the SARS-CoV-2 virus or not. It underscores the utility and usefulness of the Hierarchy of Controls.

“One thing that makes the most sense, in terms of efficiency, is having some type of an instrument management system,” infection prevention speaker, author, and consultant Mary Govoni says. “In some practices, they simply put their instruments loose in a pouch for sterilization, then they take that pouch and put it on a tray in the treatment room, open it up, use the instruments, and then have to gather them back up to take them back in for processing.”

The more the instruments are handled, the greater the opportunity for accidental exposure.

“In some cases, if there are multiple instrument setups, they have to do some sorting of those instruments after they’ve been cleaned and before they can be packaged for sterilization,” she adds. “So, [you should be] using a cassette or some kind of a container that the instruments can be taken to the treatment room and cleaned in the ultrasonic, put through the sterilizer. The instrument set up stays together all the time and increases the efficiency tremendously.”

Regrettably, not every practice embraces such a system.

“Practices resist that because of the perceived cost of investing in a cassette system,” Govoni says. “But the return on investment from increased availability of the assistants could certainly help recover that investment. And there are other devices that may be less expensive than cassettes; they’re made of plastics or resin material. They’re not as durable as a stainless steel cassette, but I would say instrument management – COVID or not – is probably the best example of a tool for efficiency, in terms of workflow.”

In the Hierarchy of Controls, where does instrument handling fall? Is it an administrative or engineering control?

“It actually can be both,” Govoni observes. “It’s a process control in that it streamlines the process, because if I have loose instruments on my tray that I’m taking to the sterilization area and then picking them up and putting them into the ultrasonic, there most likely will be other instruments from other procedures in there at the same time. That requires some sorting of instruments when they come out to group them together.

“But it is also an engineering control,” she continues, “in that the Bloodborne Pathogen Standard specifies that instruments must be transported in a covered, puncture-resistant, leak-proof container, when they’re taken from the treatment area to wherever they’re reprocessed.”

Instruments are such a ubiquitous part of the dental practice that they can sometimes be handled sloppily.

Heed the warnings

COVID-19 is, obviously, foremost in everyone’s thoughts these days, but it’s easy to forget that there were other public health crises in recent years. Unfortunately, many practices may have forgotten the lessons that they should have learned.

“We had H1N1, SARS, even MERS,” Dr Risk says. “With H1N1, people on the medical side were taking temperatures at the door. They were isolating patients – it’s called cohorting patients, which means that you put everybody that has a fever in one corner of your waiting room, and everybody that is healthy in another corner.”

Those practices have returned.

“So, now what we’re doing is we’re taking temperatures again,” Dr Risk says. “A lot of folks are taking a pulse oximeter reading, which is relatively easy to do, and they’re distancing their patients in the waiting room, much like what was recommended on the medical side, back in 2009. When you have a community spread of a virus or a bacteria or something where you’ve got this reservoir of pathogens in a group or a population that’s coming to see you, then you need to take steps to make sure that your practice is safe, that everyone else is safe. And with dentistry being more of an elective type of procedure, we have the ability to put some treatment off a week, or even two weeks, to confirm that someone is healthy.”

Practices should be looking at the whole patient and understanding what may make him or her a potential hazard.

“Rather than just taking a history and saying, ‘Has anything changed?’ they may or may not say, ‘Well, I have the flu today’, or ‘I have a cold today’, or ‘I have a cold sore today’,” he illustrates. “So, we’re kind of going back to putting into practice what we should do pretty much all the time, and that is screen our patients for infectious diseases when they come in.”


SARS-CoV-2 is especially virulent when airborne. As such, special attention is being paid while aerosol-generating procedures are performed.

“What could create efficiency problems is whether or not the hygienist has the high volume evacuation that they need, if they’re going to use an ultrasonic scaler,” Govoni says. “Some dentists are finding that their evacuation systems, their vacuum pump, isn’t adequate to have so many units running on high volume evacuation at the same time. So, they may have to upgrade their systems so that everybody’s getting good velocity on their suction, no matter where they are at in the practice.”

While being mindful of aerosols is nothing new, there is a greater attention being paid to the issue.

“That’s really something they’ve discovered since COVID,” Govoni says. “Most practices are using, or were using, pre-COVID, the high-volume for the doctor’s treatment rooms, and that’s probably what the capacity was designed for in a facility. Now, when you’re adding maybe two or three more treatment rooms where you’ve got HVE running simultaneously and doubling the need, then they find out that they just don’t have the correct capacity.”


Team members are used to following instructions, however this isn’t the time for blind obedience. Team members should, certainly, follow instructions, but they should also understand the reasoning and rationale behind such direction.

“Where does the clinician, the dental assistant, the dentist, the hygienist get their information for how they’re practicing dentistry?” Dr Risk says. “And the question becomes, are they getting it from a reliable source? And then if they’re getting it from the people that employ them, for instance, they work for a DSO and DSO Central sends down the protocol, the question then becomes, does it cover all the requirements, or can they ask questions about the protocol such as, ‘What is the goal of doing it this way? Or can we accomplish this another way? It’s not that I don’t trust it, I want to know where it came from.’ Because, most protocols and most procedures are cut-and-dried, but they don’t put in the intent. They don’t put in the ‘why’ and they don’t put in the hierarchy of risks that you’re trying to mitigate. They’re not putting in all the information that came from the original source. The intent and the ability to mitigate certain risks are critical to understanding the protocol and to compliance.”

SARS-CoV-2 has thrown a curveball at dental workers over the past year. And while new procedures and processes are necessary, the good news is that dental was already a few degrees ahead of the curve and doing the right things.

“We’ve always done a good job of infection control in practices to begin with,” Govoni says. “It started to happen in the late 80s when we were learning more about HIV and AIDS, but the really big jump happened in 1991 when the Bloodborne Pathogens Standard was finalized. Because we had those protocols already in place, we were in a better place for COVID.”