Preventing Infection in the Dental Practice

The technology continues to advance, but the tried-and-true solutions to infection control are as important as ever.

As technology becomes safer, more efficient and more affordable, dentists and their staff have access to more – and better – solutions to reducing the transmission of infection at their practice. No matter how sophisticated the products are, however, the choices remain simple: Hand hygiene and surface disinfection continue to be key to infection control.

“Hand hygiene is still considered the number one way to prevent the spread of infection,” says Evelyn Cook, associate director, Statewide Program for Infection Control and Epidemiology (SPICE), University of North Carolina at Chapel Hill, consultant for Palmero Healthcare. “In its 2002 Guideline for Hand Hygiene in Health-Care Settings, the CDC pointed out that the adherence of healthcare workers (HCWs) to recommended hand-hygiene procedures was poor, with an overall average of 40 percent.” Some of the perceived barriers to adherence included:

  • Inaccessible hand-hygiene supplies.
  • Skin irritation to soaps and hand sanitizers.
  • Insufficient time due to understaffed facilities and high workloads.
  • A tendency to devalue the importance of hand hygiene and its impact on healthcare-associated infections.

Today, it is widely accepted that “alcohol-based products are more effective for standard handwashing or hand antisepsis by HCWs than soap or antimicrobial soaps, and their availability has eliminated most of the barriers identified above,” she says.

The 2003 CDC Guidelines for Infection Control in Dental-Healthcare Settings note that even dental operatory environmental surfaces and equipment that do not contact patients directly may become contaminated during patient care, says Cook, noting that frequently touched surfaces, such as light handles or unit switches, can serve as reservoirs of microbial contamination. EPA-registered hospital disinfectant wipes, which can be conveniently located within the dental practice and used to disinfect non-critical patient care equipment and some environmental surfaces also are considered highly effective, permitting HCWs to adhere to the manufacturer’s instructions for use and contact time. (This varies by product, but in some cases can be as little as one or two minutes.)

A designated leader
All facilities providing clinical care, including dentistry, should have a designated individual who is assigned the responsibility of oversight for the infection prevention/control program, says Cook. “In 1992, the state of North Carolina effected 10A NCAC 41A .0206 Infection Prevention-Health Care Settings Rule, which requires all healthcare organizations to have a designated individual who has attended a state-approved course in infection prevention [and is qualified to be] responsible for oversight of infection prevention activities,” she explains. “This individual(s) ideally should have a clinical background with expertise in the field of dentistry.” From the start, the infection control coordinator should thoroughly assess “the size and scope of the dental practice when determining time allotment for infection prevention oversight,” says Cook. His or her responsibilities should include:

  • Develop written infection prevention policies and procedures.
  • Provide infection prevention training for all staff members.
  • Monitor compliance and infection prevention policies.
  • Assure compliance with state and federal regulations related to infection prevention.

“Although the designated individual has responsibility for oversight of the program, success occurs when all dental healthcare professionals are committed to maintaining a safe work environment,” she adds.

A comprehensive program
A comprehensive infection control program specific to dental settings is comprised of several components, according to Cook:

  • Hand hygiene: Hand hygiene policies should clearly delineate when hand hygiene is to be performed and what agent is to be used (i.e., soap and water versus an alcohol-based hand rub). Processes must be in place for training and monitoring compliance. The CDC 2016 Summary of Infection Prevention Practices in Dental Settings; Basic Expectations for Safe Care recommends that hand hygiene in dental settings should be performed:
    • When hands are visibly soiled.
    • After barehanded touching of instruments, equipment, materials and other objects likely to be contaminated by blood, saliva or respiratory secretions.
    • Before and after treating each patient.
    • Before putting on gloves and again immediately after removing gloves.

Dental clinicians and staff should use soap and water when hands are visibly soiled (e.g., with blood or body fluids); otherwise, an alcohol-based hand rub may be used.

  • High-level disinfection: Written protocols for high-level disinfection (HLD) – including documented training/competencies of staff and a schedule for quality monitoring of process – are necessary when HDL is performed in the practice.
  • Sterilization: Written protocols for sterilization should include documented training/competencies of staff and a schedule for maintenance and microbiologic monitoring of equipment. They should also include management of sterilizer failure, possible recall of instruments/equipment and patient notification if necessary.
  • Safe injection practices: As defined by the World Health Organization, a safe injection does not harm the recipient, does not expose the provider to any avoidable risks and does not result in waste that is dangerous for the community. Unsafe injection practices, such as direct or indirect syringe re-use, inappropriate use of single-dose or single-use vials and failure to use aseptic technique, are major cause of outbreaks in outpatient healthcare settings. In particular, all dental providers should ensure that staff:
    • Never administer medications from the same syringe to more than one patient, even if the needle is changed.
    • Do not enter a vial with a used syringe or needle.
    • Use single-use (single-dose) vials for one patient, one time only.
    • Dedicate multi-dose vials (if used) to a single patient if possible.
    • Always adhere to aseptic technique when preparing and administering injected medications.
  • Environmental sanitation: Written protocols are necessary for sanitation of rooms and equipment, including delineated responsibilities, procedure for cleaning, product review and a schedule for monitoring the process.
  • Post-exposure evaluation: Written protocols are necessary for post-exposure evaluation when a healthcare provider or patient has been exposed to blood or other body fluids of another person.

Implementing a program such as the above is not easy, notes Cook. “The challenges are numerous and include dedicating financial and staff resources to infection prevention and implementing standardized, valid processes for monitoring compliance,” she points out. “Monitoring compliance with the above protocols requires determining:

  • Who will conduct monitoring activities, and how often.
  • What monitoring tools will be used.
  • How the data will be collected (i.e., manually or electronically).
  • How the findings will be aggregated and communicated to staff.
  • How action plans will be developed to address opportunities for improvement.

As challenging as it may be to implement and enforce a comprehensive infection control plan, however, failing to do so places dental owners, their staff and patients at risk for illness and presents a huge liability issue for the practice. “Since 2001, more than 150,000 patients in the United States have been notified of potential exposure to hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV due to lapses in basic infection control practices,” says Cook. “Healthcare adverse events and outcomes are a continual media focus, and patient harm that occurs as the result of poor infection prevention practices is highly publicized and subject to ligation. Consequences for dental practices could include:

  • Patient illness or death.
  • Malpractice suits and legal charges.
  • Loss of license.
  • Criminal charges.
  • Loss of public trust.

The more educated clinicians and their staff are about the need for infection prevention within dental settings, the more likely they are to comply with the necessary protocols. “Educational programs should specifically discuss disease transmission and interventions to reduce the potential for transmission, such as hand hygiene, safe injection practices, and sterilization and disinfection principles,” says Cook. Current curriculums for medical professionals do not always include a focus on applying infection prevention concepts in their daily clinical practice, she adds – a point that is essential to compliance.

Editor’s note: For additional infection prevention/control resources for dental settings, visit:


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