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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.
There are things in life that one just accepts as a truism: Always wear a seatbelt; don’t smoke; never look directly at the sun. No one has to be told why; we just accept these things as fact. That same acceptance extends into dental practices when we talk about the importance of good disease prevention.
Although the significance of good infection control should be obvious, a refresher is always helpful.
The most obvious reason for good infection prevention is, of course, the safety of both patients and staff.
“Because patient safety is paramount. It’s critical,” says Leann Keefer, RDH, director, corporate education and professional relations at Crosstex International. “There’s no other way around it. As healthcare providers, we have a moral, legal and ethical responsibility to make sure that the procedures, the products and the instruments that we are using are the best for patient care. I’m passionate about infection control, but sometimes we can become complacent because we do this day-in and day-out. And that’s where we need to stay on our toes and to keep that level of awareness, using best practices and not slipping into common practices and cutting corners.”
While patient safety is important, staff safety is equally essential.
“I think that sometimes part of the complacency is we forget that we’ve got the safety of the staff to think about, too,” Keefer says. “We are exposed to bioaerosols every day. At Crosstex, our trademark quote is, ‘Because you can’t see sterile.’ Most staff members don’t think, ‘I need to wear a face mask when I’m turning a room because there are aerosols that can linger for up to 30 minutes following use of the ultrasonic scaler.’”
It can be easy to become complacent, especially when nothing bad has ever happened at the office. But just because it hasn’t happened yet doesn’t mean that something can’t happen in the future.
“Not to be morbid, but people say, ‘I’ve been doing this for 20 years and I don’t have to change,’ but there are stark realities,” Keefer says. “In the fall of 2013, the first documented report in the United States of a patient-to-patient transmission of the hepatitis C virus (HCV) associated with a dental office was issued by the Centers for Disease Control and Prevention (CDC) due to a flagrant infection control breach by an oral surgeon in Tulsa [Oklahoma]. In 2012, a case report in The Lancet detailed the death of an 82-year-old woman in Italy due to rapid and irreversible septic shock, which was caused by Legionnaires' disease, traced to the contaminated dental unit water of the high-speed handpiece equipment used for her dental surgery shortly before her death. This tragic incident happened after only two visits to her dentist in a two-week period.
“This is very real. At times, while some of these infections may not be life-threatening, they may be misdiagnosed as the patient having a fever or upper respiratory infection, for example. They’re not thinking about how it can be related to exposure from a dental office.”
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Quality of life
Joyce Moore, RDH, an infection control consultant and clinical instructor at Bristol Community College in Fall River, Massachusetts, looks at a broader view of disease prevention in the context of how regular dental care improves patients’ overall quality of life.
“It’s important, across the board, because it’s likely to improve quality of life, overall life expectancy, and it reduces the incidence of other chronic health conditions because we know that infection and disease keeps increasing healthcare costs,” she says.
“If we look at it from a dental angle, many Americans don’t have access to regular dental care,” Moore continues. “In 2014, only 43.2 percent of persons aged 2 years and older had a dental visit. When we look at dental decay, it is largely preventable, but it is the most chronic disease of all children and adolescents ages 6 to 19.”
Dental diseases, if not addressed, can spiral out of control, affecting other facets of a patient’s life.
“Chronic illness that lead to missed school time can lead to students who don’t do as well,” Moore explains. “When we talk about undetected and untreated oral disease, we are also talking about pain and disability related to work absenteeism and reduced job productivity. When we talk about disease prevention from a medical standpoint, we are looking at gum disease and other dental concerns being associated with other chronic diseases.”
Receiving the appropriate care, Moore says, is a combination of both access to care and proper education.
“When you have families that don’t have regular care, they’re not getting that education piece,” she says. “They’re not understanding why baby teeth are important to keep in order to hold the space for the adult teeth. When we don’t know better, we don’t tend to do better.”
Good infection control and disease prevention isn’t complicated; it involves things that everyone should know. For instance, poor hand hygiene is one of the biggest causes of infection but also the easiest to address.
“We see this all the time and we see it is in the media about the importance of hand hygiene protocols,” Moore says. “It’s a simple thing that everyone can do, but we’re starting to see more and more the link that hand hygiene protocols can save lives, across all healthcare facilities – not just hospital settings, but urgent care settings, nursing home settings.
“The American Journal of Infection Control published a study last month that reported when using a hand hygiene protocol that prompted staff, residents and visitors in nursing homes to wash their hands, that there was a good reduction in antibiotic prescription rates and mortality,” she adds. “We know that hand hygiene compliance is a fairly easy thing to tackle because most facilities have handwashing facilities, have products, and even have signage to remind their staff and patients about good hand hygiene protocol.”
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In order to overcome complacency and stay on top of all the proper infection control protocols, Keefer recommends a three-pronged approach.
“Obviously, with the CDC guidelines and OSHA standards, we have the ‘rules’ in front of us to keep patients safe,” she says. “We have to make sure that all members of the team are aware and know and understand – and that might be the big thing, understanding – what those guidelines and standards are saying. This has to occur with things like initial training when someone is first hired. It’s not a matter of throwing an infection control book or a set of guidelines at them and saying, ‘Here, read these.’ There has to be definitive on-boarding time for infection control and for how the office abides by those guidelines in their protocols and procedures.
“And then, there has to be additional training,” she continues. “What if somebody changes an infection control product? There may be a slight difference in the instructions for use (IFU) for similar products, so there cannot be assumptions.”
Next, the practice needs a dedicated infection prevention coordinator.
“They would handle things like administration, documentation and training,” Keefer says. “Doing direct observations to make sure IFUs and protocols are being followed is part of their day-to-day responsibilities to keep that practice, the staff and the patients safe.”
Finally, Keefer recommends checklists as a way to stay on top of the details.
“You think about airline pilots and those checklists that they use because they want to make sure they don’t miss a beat,” she says. “There are a number of checklists that are available to us in dentistry. The CDC’s Infection Prevention Checklist for Dental Settings summary document is a user-friendly, plain-language guide that takes the 2003 document and makes it usable for clinicians today. At the back of that document are two separate checklists. The first checklist looks at administrative policies and practices that should be included in their written infection control manual. The second checklist is for a direct observation opportunity for personnel compliance to make sure that they are fulfilling the infection prevention guidelines and expectations in actual practice.”
Human beings are not the only things adversely affected by poor disease prevention efforts. The dental practice, itself, is at risk.
“If we’re looking at the cost of noncompliance, it’s not a black-and-white calculation, but you can look at some very basic things,” Keefer says. “All income is going to be terminated when a license is revoked or suspended. That timeframe is affected by the severity of the breach and what it is going to take to retrain and teach the appropriate protocols. They may have to hire an infection control consultant to come in and provide that assessment, the remedial training and the risk analysis.”
The practice may be subject to fines and legal fees, too.
“Many times, when there is a sanction by a state dental board, representation by an attorney is very common,” Keefer says. “So, in addition to your lost income, you can have attorney and infection control consultant fees. Rent, malpractice insurance and utilities are all ongoing costs that can continue to add up.”
Those examples are all monetary cost, but there’s one cost that may be even more severe.
“The one ‘cost’ that you can’t quantify is the loss of patients’ trust and standing in the community,” Keefer says. “How do you put a price tag on that? If we can get people to start thinking about all financial and intangible costs, in comparison to the investment related to ensuring infection control with required products, it’s truly a pittance.”
Disease prevention – whether in the context of regular oral healthcare or infection control – is a no-brainer. We all know how important infection control protocols are, but sometimes a friendly reminder is in order.