What We Know Now about Infection Control in the Dental Practice

What We Know Now about Infection Control in the Dental Practice. Photo courtesy of Yakobchuk Olena/stock.adobe.com.

Like it or not, science is a moving target. As we learn more about the world – and as more things happen to us, like a pandemic – processes and protocols necessarily change. That is certainly the case with infection control in dentistry.

For instance, most dentists used to practice “wet-fingered dentistry”, meaning that they didn’t wear gloves while treating patients. That all changed in the mid-1980s with the HIV epidemic. Wearing gloves became standard practice to protect oneself (and patients) from the spread of bloodborne disease. Because of this new threat, healthcare professionals took a closer look at their daily practices and reevaluated protection.

But it isn’t just epidemics and pandemics that have spurred change.

Evolution

Infection control, for the most part, is static. That is, things don’t tend to change unless something big happens, but that doesn’t mean that they never change.

“I think the general principles stay relatively constant,” 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 the Organization for Safety, Asepsis, and Prevention, is a Diplomate of the American Board of General Dentistry, and is a Fellow of the International College of Dentists. “In other words, we have the 2003 dental guidelines from the Centers for Disease Control (CDC), and those still have a lot of merit. We’re not going to change a lot of that information, because it was well researched and is still valid. But between now and the last almost 19 years, we’ve taken the guidelines that we wrote and then we’ve applied them to different situations where we’ve made a concerted effort to categorize a situation, according to the guidelines or the Spaulding Classification or to the type of desired outcome that we want, thereby refining the proper protocol in those situations.”

One of the things that has changed is patient awareness, requiring team members to be able to discuss infection control with lay people.

“Infection control has come such to the forefront and patients have become very savvy,” infection prevention consultant Katherine Schrubbe, RDH, BS, MEd, PhD says. “Patients are asking a lot of questions. They ask, ‘Do you have HEPA filters? And do you throw those items away or do you reuse them?’ So, I believe infection control, in general, has become more important to both patients and teams.”

What Not to Do

For all the infection prevention measures that seem to be added, Dr Risk observes that the bigger changes seem to be in the things that the dental industry should no longer do.

“Some things that used to be commonplace should have been discontinued a while ago,” Dr Risk says. “For instance, wiping down instruments that go in the mouth. That’s really something that we should not be doing. Be it impression trays, anything that’s single use, or anything you can’t throw in a sterilizer. You can’t wipe it off and use it again. You must realize that that’s a single use for a single patient and you can’t try 1 on and then go over and clean it, disinfect it, and use it on somebody else. Another area is cold sterilization. There are so many issues with the glutaraldehyde and even the safe solutions. We really should not be using any kind of cold sterilization processes anymore, because they’re just not reliable and they’re dangerous for the environment. There are very few instruments that require cold sterilization, that don’t have an alternative that either can be sterilized or are disposable.”

Other practices that have evolved, Dr Risk observes, include:

• Sterilization of all components of handpieces and motors is required now.
• Standard precautions have expanded according to the CDC into 7 different areas — it used to be focused on personal protective equipment (PPE) and Occupational Safety and Health Administration (OSHA).
• Semi-critical tissues, such as mucous membranes, are taken much more seriously than previously. The CDC recommends instruments that touch mucous membranes in dentistry be sterilized and aseptically prepared for use.
• Decontamination and sterilization instructions may be different for different instruments, and the directions for use should include what procedures are required.
• Infection control takes training and continuous updating, just like the CDC guidelines that are continuously updated e.g., HICPAC guidelines for Disinfection and Sterilization in Health Care Facilities, 2008, updated May 2019

Hierarchy of Controls

In December 2021, the World Health Organization (WHO) deemed COVID-19 an airborne transmissible virus, which has led to more focus and attention on ventilation systems and the third level of National Institute for Occupational Safety and Health’s (NIOSH) Hierarchy of Controls – Engineering Controls.

“General workplace ventilation in our practices is important,” Dr Schrubbe says. “It’s really not something that’s been a topic of discussion in dental practices very much, but now OSHA has a document titled, COVID-19 Guidance on Ventilation in the Workplace. It applies to all workplaces and there is guidance related to your HVAC system – is it working efficiently?’ Is your practice using high filtration, MERV-13 filters? We know that if there is effective air movement, it is part of our mitigation strategies to reduce the risk of acquiring the virus.”

“With the COVID-19 introduction, now we’ve got this airborne battle that we’re fighting,” Dr Risk adds. “And so, you’ve tweaked it from, ‘Yes, PPE is important.’ And then you go and say, ‘Well, PPE isn’t that effective, so let’s go back and look at the Hierarchy of Controls.’ Are there situations that we can actually eliminate and not be exposed at all to this situation? Are there ways to mitigate the exposure? Using a rubber dam reduces the amount of exposure to oral fluids and that becomes safer. And then you go through the line: Are there situations where, yes, this situation would be okay to be exposed, but this situation’s not. And so, we put in our engineering controls.”

Checking in

As public health threats present themselves, dental practices have responded in ways that, in retrospect, should always have been in place. One such strategy is to screen patients before they are seen.

“The funny thing was that we decided, back in 2003 or so, that we should be taking information and data from patients and applying that to a risk assessment as to whether they are a carrier of disease. That kind of fell by the wayside. And then it’s back, with COVID and, then it falls off by the wayside again,” Dr Risk adds. “So, yes, there are things that we see from COVID that should be 100% all the time. We should always be asking patients, have they traveled to a region of the world that is highly endemic for a certain disease, like tuberculosis or anything like that. Then checking for symptoms and then using the appropriate protocols to mitigate any risks to the staff. We did the same thing with the H1N1 outbreak in 2009. We said everybody should be asked whether they’re sick or not at the front desk. Taking temperatures at the front desk is never a bad idea, but there’s a lot of offices and a lot of places that say, ‘We no longer have to do that, because the immediate threat is over with.’ Or people – whether they’re sick or not – will tell us, but is that really true?”

The silver lining of public health threats seems to be more laser-sharp focus on infection prevention.

“COVID drove dental to do a better screening for respiratory illness, but COVID isn’t going to be the last respiratory virus or strange thing or novel thing that we probably have to deal with,” Dr Schrubbe observes. “And although levels are down, the infectivity of the virus is still high. It’s not going to go away. And the question is always, ‘What’s next?’ It’s a good thing that we continue in dentistry, because regardless of the respiratory agent we’re dealing with, we aerosolize viruses and bacteria, and we have a potential for high risk.”

Will that screening continue even after dental practices are given the all-clear from COVID-19?

“Based on what we’ve learned, it would be a good thing if we continue that in dentistry,” Dr Schrubbe says. “Whatever the guidance comes out with in the future, many practices have been doing it now for a couple years. Why should we stop that? It’s such a great screening device to make sure that for the providers and the other patients that might be in the reception area, we going to continue to offer people protection.”

Certainly, COVID-19 has caused dental practices to reevaluate their protective measures. However, infection control is a constantly evolving field, whether there’s a pandemic or not.