Infection Prevention and Control: Implementing a Culture of Safety within the Dental Practice

Every infection control program should be approached proactively; needs should be discussed and plans for implementation, education, and training developed. To ensure effective implementation, ongoing monitoring and evaluation of the program is critical. This is where the role of the infection control coordinator becomes very important. A single individual may fill this role in a smaller practice, or a committee may do so in larger institutions. Whichever model is chosen, infection-control personnel help to develop the policies and procedures, keep them updated, and monitor relevant programs on an ongoing basis.

Along with the coordinator, checklists play an invaluable role in preventing infections. They help to remind personnel of critical steps that must be completed, such as weekly biologic monitoring. They also provide verification that the step has actually been completed. Checklists can enable reconstruction of what steps preceded any adverse event that does occur. The Centers for Disease Control and Prevention (CDC) “Guide to Infection Prevention for Outpatient Settings,” revised in November 2015, summarizes the CDC’s recommendations for infection control relevant to outpatient healthcare settings and includes a number of checklists in its appendix.¹ On March 29, 2016, the CDC Division of Oral Health released a similar publication specific to dental healthcare settings, “Summary of Infection Prevention Practices in Dental Settings—Basic Expectations for Safe Care,”¹ which elucidates the current recommendations on infection prevention. A checklist is included in the Summary that dental practices can be use to evaluate compliance.² These current recommendations are primarily based upon the CDC’s 2003 guideline and represent what the expectations are for safe care in dental settings.³

Additional topics that have been updated by the CDC since 2003 and are relevant to dental practices include:¹

• Administrative measures for infection prevention programs

• Education and training

• Respiratory hygiene/cough etiquette

• Updated practices for safe injections

• Administrative measures for instrument processing

The Summary should be used by anyone in a practice who needs information about basic infection prevention and control measures; however, it is not intended to replace the more extensive guidelines. Because of this, the author encourages all readers to consult the full guidelines for the background, rationale, and evidence behind each of the CDC’s recommendations.¹

Within the dental healthcare setting, Standard Precautions incorporate major features of universal precautions in healthcare.^1,3,4 Standard Precautions, for those who may be unfamiliar with them, are the minimum, universal set of infection prevention and control practices that apply to all of patient care, both medical and dental. These precautions apply regardless of any suspected or confirmed infection status, and they apply in any setting where healthcare is delivered to a patient. These precautions are designed both to protect dental personnel from contracting infections from patients, and to prevent dental healthcare personnel (DCHP) from spreading infections among patients. Standard Precautions include:

• Practicing proper hand hygiene

• Wearing personal protective equipment (PPE)

• Practicing safe respiratory hygiene/cough etiquette

• Engineering/work practice controls for sharps safety

• Safe injection practices

• Safe sterilization of instruments and medical/dental devices

• Properly cleaning/disinfecting environmental surfaces

Effective implementation of standard precautions requires administrative measures, engineering controls, and safe work practices. Devices that remove or isolate a hazard are engineering controls, while work practices relate to how those engineering controls are used and how healthcare workers carry out their tasks.

Respiratory hygiene and cough etiquette are important for both healthcare workers and the general public every day. These include simple things like covering one’s cough using a tissue, disposing of tissues in the nearest waste receptacle, and keeping hands clean. To remind patients of these good practices, the waiting room should be carefully scrutinized. Do patients have access to hand sanitizers? Does the room contain tissues and a waste receptacle, as well as signage reminding people to cover their coughs or use tissues? Such objects communicate to patients that they are in a place where infection control is taken seriously.

A related question is how to best handle patients who have respiratory symptoms, coughs, fevers, and/or colds. At times it may be advisable to defer the care of such individuals until they are no longer contagious and thus will not transmit their respiratory infections to other patients and practice personnel. In most cases, the CDC recommends this.^1,4,5 Even in emergency situations, patients often can be treated with antibiotics and/or pain control agents.

Another area of standard precautions addresses safe injection practices, ie, aseptic techniques for parenteral medication. Current CDC recommendations include avoiding administration of medications from one syringe to more than one patient, even if the needle is changed; using single-dose vials for parenteral medications whenever possible; refraining from combining any leftover contents of single-dose vials for later use; and using all fluid infusion and administration sets (ie, IV bags, tubing, and connections) for only one patient and then disposing them properly.^1,3

More than 20 years ago, Dr. Chester J. Summers at the CDC outlined four key principles for practical infection control in oral healthcare settings.⁶ These still provide a valuable framework for anyone attempting to implement a culture of safety within the dental practice.

Principle 1: Taking Action to Stay Healthy

This area includes immunizations for healthcare personnel, procedures for dealing with occupational exposure to blood and other bodily fluids, and appropriate hand hygiene.

The most important guidance for healthcare personnel immunization comes from the CDC and the Advisory Committees on Immunization Practices (ACIP).^1,3,7-9 The CDC guidelines state that because of their contact with possibly contagious patients and/or infectious material from those patients, many healthcare professionals, including DCHP, are at risk for being exposed to vaccine-preventable diseases.^1,8 Therefore, well-managed vaccination programs have the potential to substantially reduce both the number of susceptible healthcare professionals interacting with patients and the risks of transmitting vaccine-preventable diseases to patients, other healthcare professionals, and other contacts.⁷

The advisory committees most recently updated their recommendations for healthcare personnel in 2011.⁸ The hepatitis B vaccination should be given in three doses, and then followed by testing for an antibody response to hepatitis B surface antigens (anti-HBs). Vaccination is indicated for any DCHP who come into contact with blood, have contact with patients, and are at ongoing risk for sharp-instrument or needlestick injuries. This testing should be done 1 to 2 months after the third dose of vaccine has been administered. Since the mid-1990s, the CDC has recommended this for newly immunized healthcare personnel, but for individuals previously immunized prior to the mid-1990s, the antibody titer was not recommended.⁸ This changed in 2013, when the guidelines pertaining to hepatitis B vaccination were updated.^1,10 Currently, the CDC recommends that any healthcare workers who have not been tested for hepatitis B surface antigen get blood drawn to assess their antibody levels. If the level is less than 10 international units/mL of blood, one dose of vaccine should be given, followed by an antibody titer, or the series should be repeated and followed by an antibody titer. This change affected employer obligations under the OSHA Bloodborne Pathogens Standard. OSHA requires that employers provide access to the hepatitis B vaccine in accordance with the current Health and Human Services Administration (HRSA) recommendations.¹¹

The CDC also recommends that healthcare personnel receive influenza vaccine every year.^8,9 Personnel born in 1957 and later and have no evidence of immunity or previous vaccination for measles or mumps should receive two doses of measles, mumps, and rubella (MMR) vaccine 4 weeks apart. Those lacking immunity only to rubella may only need one MMR dose. Healthcare workers who have had at least one dose of tetanus, diphtheria, and pertussis vaccine should have a Td booster every 10 years. Two doses of varicella (chickenpox) vaccine given 4 weeks apart are recommended for healthcare workers who have not had the vaccine or lack serologic evidence of immunity. Those who are routinely exposed to isolates of Neisseria meningitidis are urged to get one dose of meningococcal vaccine.^8,9

The CDC website should be checked regularly to see if the immunization recommendations have been updated. Typically such updates occur in the fall.⁹

Screening for tuberculosis (TB) can be accomplished with tuberculin skin testing and a TB blood test. The skin test uses a purified protein derivative of a variety of mycobacteria, and anyone who has had a bacille Calmette-Guerin (BCG) vaccine will always test positive.¹² In such cases, the blood test is recommended. Two types of Interferon-Gamma Release Assay (IGRA) are commonly used for this; both look at interferon specific to Mycobacterium tuberculosis.¹³ While this screens for antibodies, it is not a definitive diagnosis of TB. The CDC states that TB screening frequency should be based on the risk involved.^1,3,12 CDC recommends that all DCHP be screened for TB when they are hired, regardless of the risk classification of the practice setting.^1,3,12 In most dental healthcare settings, that risk is low, meaning there has been no transmission of tuberculosis in the practice. If an exposure/transmission occurs, the risk category increases.^1,3,12

Another important consideration is work-related illnesses and worker restrictions for healthcare personnel. Policies should encourage all such workers to report their illnesses or exposures to highly contagious infectious agents such as the common cold, influenza, and conjunctivitis without jeopardizing wages, benefits, or job status. A clearly written policy should spell out this out and be communicated via education and training. Personnel should remain at home for at least 24 hours after they are symptom-free, including having no fever without the use of fever-reducing medication.^1,3,5

In the area of hand hygiene, the CDC recommendations stipulate that DHCP should clean their hands when they are visibly dirty after touching contaminated objects. As well, hands should be cleaned before and after patient treatment, before glove placement, and after glove removal.^1,3 For routine dental procedures, restorative procedures, hygiene procedures, and examination procedures, the CDC states that liquid or powder detergent and water is adequate, although this can be combined with an antimicrobial soap that has been cleared by the FDA for healthcare settings.^1,3 Alcohol-based hand rubs are not cleaning agents; the hands must first be clean for the alcohol-based hand rub to have the appropriate antiseptic effect.

A specific surgical hand-scrub technique should be employed before carrying out surgical procedures including the incision and excision of any hard or soft tissue, biopsies, periodontal surgeries, and surgical tooth extraction.^1,3 This technique should be followed using antiseptic hand wash agents specifically cleared by the FDA for healthcare settings, either in one or two steps and followed by the use of an FDA-approved alcohol-based hand rub and sterile gloves.

Inspection of the hands after glove removal is especially important. It is easy to accidentally touch the outside of the glove, especially the second one, during removal. If the hands do not appear to be dirty, the DHCP can use an alcohol-based hand rub. If the hands are visibly soiled, they should be washed with soap and water.

Principle 2: Avoiding Contact with Blood and Other Potentially Infectious Material

Summers’ second principle involves methods of avoiding contact with blood and other potentially infectious material. Many types of PPE exist, including gloves, protective eye wear, facemasks, and face shields to prevent spatter contamination and protect the nasal area and mouth. Protective eyewear has solid side shields to protect the ocular mucous membranes from spatter contamination.^1,3,11 Facemasks should always fit well and be sized to adequately cover not only the face but also any facial hair. The OSHA bloodborne pathogens standard requires that gown sleeves be long enough to protect the DHCP’s forearms when the gown is worn as PPE (ie, when blood spatter and spray, saliva, or other potentially infectious materials coming into contact with the forearms is anticipated). If penetrated by blood or other potentially infectious fluids, DHCP should change their PPE as soon as possible; they should also change it when it becomes visibly soiled as soon as is reasonably feasible. All PPE should be removed before leaving the DHCP’s work area.^1,3,11

Another area of preventing injuries and the spread of infection relates to sharps. In dentistry, this typically involves two categories: sharps with engineered safety features and safety syringes for the administration of local anesthesia. OSHA requires employers to consider procedures and technology that can reduce the risk of needle sticks and other sharps injuries.¹¹ OSHA also states that a program must be in place to document the consideration and use of effective safety devices as well as a mechanism for evaluating whether safe practices can be implemented.¹¹ Optimally, the evaluation should include more than just one individual or an administrator, and the individuals who are working with the sharps or disposing of them should also do the evaluation. The CDC provides a number of resources on its website, including a workbook and evaluation tool for assessing and evaluating local anesthetic syringes that engineer safety features (eg, aspirating syringes and safety needle systems).¹⁴

Selecting and using devices with engineered safety features and establishing safe work practices can significantly reduce the risk of exposure incidents. Exposures, however, can still occur. It is important to establish a well-written and implementable post-exposure management program. Policies and procedures should be in place well in advance of exposures occurring, and all healthcare personnel should be educated and trained. Training should be done on a routine and regular basis, at least annually, and it should remind people of where to go, what to do, and to whom to report. It also should help workers to think about how exposures could have been prevented from occurring.^3,11

Principle 3: Eliminating the Spread of Contamination

Proper preparation of the operatory before the start of treatment is another important tool for thwarting the spread of infectious agents. The transmission of both hepatitis B and C through contact with environmental surfaces has been demonstrated in outbreaks among patients and staff of hemodialysis units.¹⁵ Hepatitis B has been demonstrated to survive in dried blood on environmental surfaces for at least 1 week.¹⁶ In vitro studies have shown that hepatitis C can remain infective on dry surfaces for up to 6 weeks.^17,18

Measures that can limit the spread of infection include such steps as stocking unit-dose supplies, covering surfaces that could become contaminated, minimizing sprays and splashes, and properly disposing of all medical waste.^1,3

Environmental surfaces are divided into two main categories: clinical contact surfaces and housekeeping surfaces. Housekeeping surfaces, such as floors, walls, and sinks, have a more limited risk of disease transmission than patient-care items and clinical contact surfaces, and therefore they can be decontaminated with less rigorous methods than those used surfaces that come into direct contact with a patient during the course of care. Cleaning and disinfecting strategies in patient-care areas should consider the following criteria: the potential for direct patient contact; the degree and frequency of hand contact; and any potential contamination of a surface with bodily substances or environmental sources of microorganisms (eg, soil, dust, or water).^1,3

After clinical contact areas have been identified, the next step is to consider whether the infected area is smooth and hard. If so, it can be cleaned and disinfected. In contrast, irregular surfaces such as switches, connections, hoses, nozzles, etc, should be covered with a barrier that can be changed between patients. If the underside of the barrier becomes contaminated, that area will require cleaning and disinfection, followed by replacement of the barrier. Otherwise, the barrier can simply be changed. Alternatively, smooth, hard clinical contact surfaces can be cleaned and disinfected. The CDC recommends the use of an EPA-registered low- to intermediate-level hospital disinfectant.³ It must be noted that the EPA does not register or label disinfectants as “low” or “intermediate.” Instead, labels list specific organisms that the disinfectant has been demonstrated to kill or inactivate. Low-level disinfectants have the ability to kill or inactivate vegetative bacteria, viruses, and fungi. Intermediate-level disinfectants list M tuberculosis among the organisms against which they are effective. If the label has M tuberculosis in the list of organisms it claims to inactivate, then it is an intermediate-level disinfection. If M tuberculosis is not listed then it is a low-level surface disinfectant.³

Under certain circumstances, it may be preferable to cover smooth clinical contact surfaces. For example, a light handle is smooth and hard, but many disinfectants over time may cause some corrosion to stainless steel, or may discolor powder-coated steel. Patients may interpret such corrosion or discoloration as dirt or decay.

When using pre-moistened disinfectant towelettes or disinfectant wipes, as many practices now do, it is extremely important to read the accompanying instructions for use. The instructions should make it clear if the wipe product can be used for cleaning and disinfection (eg, one wipe to clean a surface and a second wipe to spread the disinfectant onto the surface). If the instructions indicate that surfaces should be pre-cleaned prior to using the wipe to apply the disinfectant, then the product can only be used for the disinfection step. It is also important to keep the lid on the wipe container closed when not in use to prevent drying of the wipes/towelettes. The CDC recommends following the specific product manufacturer’s instructions for use.^1,3

Principle 4: Making Patient-Care Items Safe for Use

A final principle is to ensure that reusable patient-care items are safe for use. This may be accomplished through cleaning, packaging, and sterilization. Items that go into the patient’s mouth are classified as semi-critical (touching mucous membranes) or critical (penetrating mucous membranes). The CDC recommends healthcare personnel follow the specific manufacturer’s instructions for reprocessing semi-critical and critical reusable patient care items. Items designated as single-patient use must be properly contained and disposed of.^1,3

Whether the sterilization or instrument-processing area involves one or multiple rooms, there should be a clear segregation between the areas for receiving dirty items, cleaning and packaging items, and sterilizing them. Sterile packages of instruments should be stored in clean and dry areas to prevent compromising the packaging material.^1,3

The task of transporting dirty items to the sterilization area should also be carefully considered. The CDC recommends and OSHA regulations regulate the use of a transport container with a solid bottom and sidewalls and a biohazard label.^1,3,11 Anyone picking up, transporting, cleaning, or packaging contaminated instruments should wear puncture-resistant gloves (eg, utility or housekeeping gloves) to prevent sharps injuries.^1,3,11

According to the CDC, dental handpieces and other intraoral devices attached to air and water lines should be cleaned, packaged, and heat-sterilized.^1,3 Manufacturers’ instructions for cleaning, lubricating, packaging, and sterilizing such devices should be followed, both to ensure maximum effectiveness and to increase device longevity. Manufacturers must provide validated processing instructions for any item such as burs, diamonds, endodontic files, etc, if they are to be used for more than one patient. If the manufacturer cannot provide validated reprocessing instructions, they should be considered single-patient use items.^1,3 Today there are many single-use burs, diamonds, endodontic files, etc, manufactured and distributed for dentistry.

For packaging of instruments, the CDC recommends exclusively using material cleared by the Food and Drug Administration for medical instrumentation.^1,3 Different material types are available, including plastic paper pouches, sterilization wrap, and more. It is important to use the appropriate packaging material for the sterilization method being used. In most cases, this is steam sterilization, with which many materials are compatible. Labeling all packaging is important for a number of reasons. Label information should include the date and cycle load and identify which sterilizer was used, if the practice has more than one. If the packing material has an expiration date, then it may be prudent to put that date on the package as well, if the items will not be used in the near future. In the event of sterilization failure, knowing which sterilizer was involved will facilitate accurate retrieval of instrument packs from the inventory of the failed load as well as all packs in inventory to the last past spore test load for that sterilizer. All labels should be applied so that they are capable of remaining securely affixed to their packages throughout the entire course of the sterilization process. If a marking pen is used to label paper/plastic pouches, the labeling information should be written only on the plastic side of a plastic/paper pouch. Writing on the paper side may damage the packaging material and compromise the barrier protection. It is important to follow the specific manufacturer’s instructions for use.

Mechanical, chemical, and biologic monitoring are vital components of the sterility assurance program. To ensure the effectiveness of the sterilization process, the CDC recommends using mechanical, chemical, and biologic monitors according to the appropriate manufacturer instructions, and also maintain sterilization records in accordance with state and local regulations.^1,3

Discussion

The CDC’s “Summary of Infection Prevention Practices in Dental Settings—Basic Expectations for Safe Care,” published in March 2016, contains a two-part checklist that can be used to periodically evaluate a dental practice’s compliance with CDC-recommended infection-prevention practices. Section I of the checklist evaluates the Administrative Measures (eg, education and training, immunizations, written policies, and procedures, etc). Section II of the checklist, Direct Observation of Personnel and Patient-Care Practices, can be used to periodically evaluate compliance with correct infection-prevention practices by observing DCHP during the performance of their duties.

Another valuable resource for infection prevention and safety is the Organization for Safety Asepsis and Prevention (OSAP; www.osap.org). A not-for-profit organization, OSAP’s membership is made up of clinicians, educators, researchers, and industry representatives who advocate for the safe and infection-free delivery of oral healthcare. With its strong network of recognized experts in the field, OSAP focuses on strategies to improve compliance with safe practices and offers an extensive online collection of resources, including publications, FAQs, checklists, and toolkits that help dental professionals deliver the safest dental visit possible for their patients. 

Conclusion

Both now and in the future, new diseases will continue to emerge or re-emerge; therefore, it is important to depend on reputable sources such as the CDC and state health departments for updated information relevant to the dental healthcare setting. Policies and procedures consistent with current recommendations can then be developed within each dental practice. All infection control programs must be evaluated on an ongoing basis to identify and change inappropriate practices and improve overall effectiveness. Some strategies and tools for accomplishing this evaluation include conducting periodic observational assessments, using checklists for documenting procedures, and conducting a routine review of occupational exposures and illnesses. 

About the Author  

Kathy J. Eklund, RDH, MPH, is Director of Occupational Health and Safety and Patient Safety Advocate at the Forsyth Institute, Cambridge, Massachusetts, and an adjunct instructor in dental hygiene in the School of Applied Sciences at Mount Ida College in Newton, Massachusetts, and adjunct assistant professor at Massachusetts College of Pharmacy and Health Sciences, in Boston Massachusetts. She is an author of the 2003 CDC Guidelines for Infection Control in Dental Healthcare Settings. She is a member of the American Dental Hygienists Association, the Organization for Safety Asepsis & Prevention, the American/International Associations for Dental Research, and the American Dental Education Association.

Disclosure

Ms. Eklund received an honorarium for her preparation of the webinar program upon which this manuscript is based.

References

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11. US Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910. Occupational Exposure to Bloodborne Pathogens; Needlestick and Other Sharps Injuries; Final Rule. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=16265.

12. The Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR Recomm Rep. 2005 Dec 30;54( RR-17):1-141. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5417a1_e. Accessed June 21, 2016.

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