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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. 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.
There’s a tendency to think that the only place infection control matters is in the operatory, but that is, of course, not true. Being mindful of infection prevention should extend to all areas of the dental practice.
OSHA mandates preventative measures to protect employees, but those measures would, certainly, extend to patients.
“OSHA’s Bloodborne Pathogen Standard requires employers to define the risk areas in their facility,” says Mary Borg-Bartlett, president of SafeLink Consulting. “The risk areas would be anywhere that potentially infectious items could present a risk to the employees. Other than the obvious areas, such as treatment rooms and the sterilization room, the areas that come to my mind that could be contaminated by staff would be hallways, the patient checkout area, restrooms, laundry rooms, private offices and storage areas for biohazard waste.
“Contamination of all of these areas could occur when healthcare personnel don’t remove contaminated gloves, gowns, etc. prior to entering these areas,” she continues. “Strict guidelines need to be developed regarding when protective clothing is considered ‘contaminated’ and when it is required to be removed. The Bloodborne Pathogen Standard defines contaminated as ‘The presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.’ It further states that ‘If a garment(s) is penetrated by blood or other potentially infectious materials, the garment(s) shall be removed immediately or as soon as feasible.’”
There’s no hard and fast list of areas that require appropriate infection prevention measures; rather, it’s up to the practice owner’s best judgment.
“All of the frequently touched surfaces in the public areas of the office where both patients and staff go should be wiped down with a surface disinfectant, at least at the end of every day, if not more frequently,” says Jackie Dorst, RDH, BS, an infection prevention consultant and speaker. “I’m talking about door handles and any doors that push open, countertops and the front desk. Frequently, patients come in, place their personal items on the counter, and they touch the countertop. It would be appropriate to wipe down the countertop with disinfectant.”
Some thought should go into considering areas that need to be disinfected. Some of the less obvious areas also require attention.
“Many dental offices have what they call a ‘primp mirror,’” Dorst says. “It’s a mirror that’s at the check-out area of the front desk. Patients, after they’ve been in the dental chair, use it. Women will reapply their lip stick or lip balm; maybe they’ve got a little bit of impression material left on their cheek or something. There are tissues by the mirror for patients to freshen up. The ‘primp mirror’ area should also be cleaned. Maybe use a household disinfectant. It doesn’t necessarily have to be the healthcare disinfectant that we use in the operatory, but paying attention to those high-touch areas will prevent disease transmission from patients as they are flowing through your practice.”
Susceptible areas should be cleaned and disinfected on a regular schedule.
“On a routine basis, I would schedule it at least every day,” Dorst says. “In offices, such as periodontal or oral surgery-where patients may be exiting the operatory and perhaps still have bleeding, or they’ve got a gauze square in their mouth and are compressing until the bleeding stops at the site where treatment was provided-those patients will be standing at the front desk with bloody gauze in their mouth. Obviously, when that patient exits, then it would be appropriate to wipe down and disinfect any surfaces that they have come in contact with. Maybe if they’ve gone in the bathroom and there’s a possibility that they have spread the blood or saliva in the bathroom, I would definitely recommend going in and doing a wipe down after that patient exits.”
It isn’t just how often an area is cleaned, but in many cases, how is just as important.
“Dirty laundry, whether laundered on site or by an outside commercial service, should be retained in an area that will prevent contamination,” Borg-Bartlett says. “The container should be the type that can be decontaminated, even if it contains a biohazard bag, and it should have a closure that prevents contact with the dirty laundry during storage. Most of the issues seem to stem from the use of washers and dryers within the practice. It’s not uncommon to see dirty gowns being thrown directly into the washer and overflowing out of the washer at busy times. The dental practice should define the risk areas and limit the wearing of contaminated PPE to those areas.”
“When they’re going to put contaminated laundry into the washing machine, the staff should wear a pair of gloves to take those items out and put them into the washing machine,” Dorst adds. “You wouldn’t want the laundry area located close to the staff lounge. Sometimes the logistics of having limited square footage in the office can make that difficult, but, obviously, you don’t want dirty laundry in a place where the staff is going to be eating their lunch.”
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In a 2016 publication, the Centers for Disease Control and Prevention advised every dental facility to have a plan governing infection control for nonclinical areas. The plan begins as soon as the patient walks through the front door.
“Every practice should have a protocol for how they’re going to handle infectious patients,” Dorst says. “Really, infection control starts at the front door. As soon as patients come through the front door, the front desk is their first contact. And what the CDC further tells us is that we shouldn’t treat patients that have a temperature of 100° F.
“If we have a patient arrive that looks like they could be sick, has watery eyes, flushed in their face, maybe coughing excessively, then it would be appropriate for the front desk to say, ‘How are you feeling today?” she continues. “It looks like this might not be a good day for you.’ And if the patient says, ‘I think it’s just an allergy. I’m okay. I’m here for my scheduled appointment,’ then what I would recommend is that the front desk has disposable paper thermometers and say, ‘Let’s just be sure. Here is a disposable thermometer. Put this in your mouth, leave it for a minute or so, and then we can see if you have a temperature.’ And with having it as a disposable thermometer, the patient can remove the thermometer, and if their temperature is above 100° F, the front desk has a justification to say to the patient, ‘I’d recommend that you go see your doctor. You’ve got a little bit of a fever. Let’s reappoint you for your dental appointment and schedule it at time that you’re not running a fever.’”
However, just because a patient shows up sick doesn’t mean that he or she can’t get emergency care if needed.
“The office will have patients that show up who need emergency care – they may have a toothache, a broken tooth,” Dorst says. “For those patients who are infectious, who may be ill, then they have a short visit, or a comfort visit. You don’t have to do a full visit. When a patient presents like that and they are feverish or they are sick, and maybe they’ve got an abscessed tooth, then it would be appropriate to immediately take them back to the operatory. If the dentist wants to look at an X-ray, then take a radiograph. The doctor can then give them prescription for pain or an antibiotic, whatever is needed to get that patient comfortable until the infection has resolved, their fever is down, and then get them back for the dental treatment that requires a longer appointment. You don’t want to leave an infectious patient sitting in your reception room, waiting for an hour or so to work them into a full schedule.”
Dorst suggests an easy, nonconfrontational way to suggest that ill patients reschedule their appointments is with a friendly sign placed on the front desk. She created one for her clients listing a number of symptoms, including fatigue, nausea, vomiting, aches and fever, reading, “Please let our team know. Your comfort and safety are our first concern.” She added some emoticons to further soften the message’s tone.
“That lightens the message to the patient,” she says. “That’s so much more friendly to the patient than having the staff sergeant personality at the front desk who crosses her arms and says, ‘If you’re sick, get out.’”
Additionally, she recommends an infection prevention station for patients who need it.
“Maybe put a box of tissues and some hand sanitizer out,” Dorst says. “Then, underneath that box of tissues, put a trash can because if the patient comes in, they might wipe their nose or one of their children’s noses with that tissue, and if you don’t have a trash can available, the next thing they’ll do is either lay the contaminated tissue down on a counter or try to hand it to the staff that’s behind the desk, and that’s a big risk for cross-contamination.”
Infection prevention is, of course, critically important in so many areas of the practice. However, it’s also good idea to send an overt message that the practice takes infection control seriously. That’s accomplished by putting one’s best foot forward.
“It’s important to communicate to patients the cleanliness of our offices,” Dorst says. “I often use the phrase, ‘From the parking lot to the back door.’ Our office has to look clean and well maintained as a healthcare facility. I can’t emphasize enough routine maintenance from the front door to the back door of the office. If the facility is getting tired and worn, the carpet is dirty at the front door, and there are fingerprints on the reception desk, then patients are going to think that that same neglect is occurring in the operatory and the sterilization area. That visible contamination can plant seeds of questioning safety and quality of care in the patient’s mind.
“The other side of the coin is when the patient enters the front door and they see a pristine environment and they see a clean reception room and reception desk, that same sparkle and shine throughout the practice, it reassures them that attention is being paid to all the details that are going to protect their safety and well-being,” she adds.