Infection Control Compliance
Issues with compliance can decrease the effectiveness of a practice’s infection prevention program
Dentistry has made significant progress in implementing infection control precautions over recent decades. Increased protection against microbial cross-contamination and cross-infection during patient care continues using a number of effective procedures, technologies, and protocols. These have included: the use of routine precautions that consider all patients as being potentially infectious (ie, standard precautions); effective hand-hygiene practices; immunization of healthcare personnel against vaccine-preventable diseases; personal protective equipment (PPE), such as gloves, masks, protective eyewear, and clinic attire; monitorable heat sterilization of heat-stable items used intraorally; disposable covers and/or broad-spectrum antimicrobial surface disinfectants for environmental asepsis; the prevention of sharps injuries by using safe work practices and engineering controls; and the adoption of a variety of dental water-treatment systems. When taken together, these infection-control program components have greatly reduced occupational exposure risks for both clinicians and patients alike. Dentists and dental assistants who have been treating patients since before the early to mid-1980s can appreciate how many of the precautions adopted then have become so routine during today’s patient care.
Central to the adoption of the practices currently in place have been the efforts of health agencies such as the Centers for Disease Control and Prevention (CDC),1-3 the American Dental Association (ADA),4 and other health organizations in developing periodic, updated evidence-based guidelines and recommendations. These incorporated the most currently available scientific, clinical, and epidemiological medical/dental knowledge to assist clinicians in comprehending not merely the “what,” but the “why” regarding the efficacy of infection control measures. The rationale here is to foster better understanding, thereby assisting in increased compliance with specific precautions. One important fact to remember when considering the issue of infection control compliance is that, while new technologies and products continue to appear, proven, long-standing, fundamental infection control principles have not changed. Unfortunately, healthcare providers can occasionally take effective routine practices and protocols for granted, and use unwarranted shortcuts because of a perceived sense that they are already protected more than necessary. Issues with compliance can decrease the effectiveness of a practice’s total infection prevention program.
The following discussion will consider this issue by using two representative clinical practices observed in dental settings. Potential problems and the rationale for proper infection control adherence will be incorporated into each discussion section.
While cleaning tissue- and blood-contaminated dental instruments in the instrument-processing sink after a long periodontal procedure, a dental healthcare professional was working without glove protection and using a short scrub brush. This scenario (Figure 1) created an increased risk for an indirect contact exposure. This type of incident occurs when infectious microorganisms are transferred indirectly through contact with a contaminated intermediate object, surface, or person. In this instance dental healthcare providers could easily scrape their hands with a contaminated instrument while cleaning them. Even though hand scrubbing will remove most organic debris, it remains the least effective way to clean prior to sterilization of contaminated items. The use of effective engineering controls (such as the use of mechanical instrument cleaning devices) and work practice controls (wearing of proper PPE including heavy-duty utility gloves) are recommended and could help greatly reduce the chance of an accidental exposure incident in this case. While manual cleaning of contaminated instruments is not “banned” in the 2003 CDC guidelines, mechanical instrument cleaning is recommended over hand scrubbing. The 2003 guidelines clearly instruct healthcare providers to use automated cleaning equipment such as an ultrasonic cleaner or instrument washer to remove debris. In addition, practice controls are recommended to minimize contact with sharp instruments if manual cleaning is necessary. These include using a long-handle brush rather than a short one.
Mechanical cleaning with ultrasonic units and instrument washers is more effective than manual cleaning.5,6 If instruments are scrubbed manually, puncture- and chemical-resistant, heavy-duty utility gloves should be worn. Also, PPE such as a mask, protective eyewear, and protective clinic attire should be worn.3
Many oral healthcare providers may not be aware that their current infection control practices are incorrect. They may or may not believe that a real risk exists because they has not become ill over a number of years. Despite personal feelings, all healthcare workers who may experience occupational exposures are required to participate in training programs at the time of employment, and at least annually thereafter. While these provide reviews and updates on cross-infection risks and preventive measures, they also allow opportunities for discussion of possible problem areas, such as described here, where lack of compliance results in the compromising of personnel safety.
When visiting a dental office, the author observed that clinical contact surfaces were being wiped down with low-level disinfectant wipes purchased from a grocery store (Figure 2). Because the same brand name on the over-the-counter disinfectant was also on the dental supply catalogue product, and therefore the products seemed to be the same, the over-the-counter variety was purchased and used for clinical contact surfaces.
Clinical contact surfaces are those surfaces in the dental operatory that have come in contact with the patient’s oral spray or spatter, contaminated instruments, devices, hands, or gloves. Chemical germicides formulated for use on inanimate surfaces and objects, such as countertops, light handles, floors, and walls, are regulated and registered by the Environmental Protection Agency (EPA). If visibly contaminated with blood, environmental surfaces must be disinfected with an EPA-registered, intermediate-level disinfectant capable of killing Mycobacterium tuberculosis, Pseudomonas aeruginosa, Salmonella enterica, and Escherichia coli, as well as hydrophilic viruses (such as hepatitis B virus), and lipophilic viruses (such as herpes viruses), after each patient appointment. M tuberculosis is used as a major test microorganism for disinfectant efficacy because of the chemical resistance provided by its outer cellular wax and lipid layers. It is considered to be among the more resistant microorganisms after bacterial endospores. Separate test data, obtained with EPA-recognized assays, must be submitted by the manufacturers and approved by the EPA to allow inclusion of a “tuberculocidal” claim on product labels and literature.
An intermediate-level surface disinfectant should have as many ideal characteristics as possible, including: being broad spectrum (including tuberculocidal and virucidal activity); having a rapid antimicrobial kill time; unaffected by physical factors, such as blood or saliva; being non-toxic and non-allergenic; compatible with surfaces in the operatory; having a residual antimicrobial effect on treated surfaces; easy to use; odorless; and economical. While the “ideal” surface disinfectant does not exist, each of these properties must be taken into consideration when choosing a product. One of the properties listed above is for the product to have a rapid cidal effect. Obviously, a shorter tuberculocidal “kill time” helps to ensure more rapid efficacy and can enhance staff compliance.7-9
In this scenario, consideration of the product’s antimicrobial spectrum and documented efficacy may not have been adequately addressed. This very possibly could have been due to providers being unaware of guidelines that assist in the selection of appropriate surface disinfectants. Even with products having similar names, the active ingredients and/or their concentrations can vary greatly between over-the-counter disinfectants and EPA-registered intermediate-level disinfectants. When in doubt, the label of the disinfectant should be checked to make sure the product has tuberculocidal capability, or the EPA website consulted for actively registered hospital-grade intermediate-level disinfectant products. Finally, products must be used in compliance with manufacturers’ instructions printed on the label.
A good understanding of fundamental principles and rationale for infection control practices should logically increase compliance with specific precautions. One consideration for improving compliance is to think about and discuss possible misconceptions and the effect they can have on important components of the practice’s infection prevention program. These can range from concern that infection control precautions do not guarantee 100% protection to statements saying that many portions of established recommendations are really nothing more than “overkill.” These examples represent two ends of the spectrum. Unfortunately, a common thread that runs through these types of comments is the misplaced belief that each infection control procedure or product should provide an absolute safeguard for the healthcare worker and/or the patient. One suggestion to resolve this is to evaluate infection control measures according to their efficacy in providing a dual benefit. This includes: 1) the ability to afford an acceptable level of effectiveness and safety as a stand-alone procedure (ie, hand-hygiene practices and the use of practice controls to prevent accidental sharps exposures when recapping needles); and 2) each practice also should provide an overlapping margin of protection with and for other protocols that are also in place. The latter is exemplified when appropriate PPE is worn, automated instrument cleaning units are employed, and cassettes are used when reprocessing contaminated instruments. Each is important to protect personnel from sharps accidents.
Each infection control procedure and protocol reinforces the others. While the potential for occupational risks are not eliminated even when the best infection control practices are employed, the door may be unknowingly opened for increased microbial cross-contamination and cross-infection when compliance wanes.
1. Centers for Disease Control and Prevention. Recommended infection control practices for dentistry. MMWR. 1986;35:237-242.
2. Centers for Disease Control and Prevention. Recommended infection control practices for dentistry. MMWR. 1993;41(RR-8):1-13.
3. Centers for Disease Control and Prevention. Guidelines for infection control in dental health care settings – 2003. MMWR. 2003;52(RR-17):1-68.
4. ADA Councils on Scientific Affairs and Dental Practice. Infection control recommendations for the dental office and the dental laboratory. J Am Dent Assoc. 1996;127:672-680.
5. Miller CH, Palenik CJ. Sterilization, disinfection, and asepsis in dentistry. In: Block SS, ed. Disinfection, Sterilization, and Preservation. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2001:1049-1068.
6. Miller CH, Tan CM, Beiswanger MA, et al. Cleaning dental instruments: measuring the effectiveness of an instrument washer/disinfector. Am J Dent. 2000;13:39-43.
7. Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). 2003;52(No. RR-10):1-42.
8. Molinari JA. How to choose and use environmental surface disinfectants. In: Cottone’s Practical Infection Control in Dentistry. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:185-193.
9. Centers for Disease Control and Prevention. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.
About the Authors
John A. Molinari, PhD
Director of Infection Control
The Dental Advisor
Ann Arbor, Michigan
Marie T. Fluent, DDS
The Dental Advisor
Ann Arbor, Michigan