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For years hygienists have followed best practices for infection control, protecting themselves and their patients from cross contamination in treatment rooms. But routine, rote, repetitive procedures lend themselves to being performed on "automatic pilot" mode, and the many steps to infection prevention in dental settings can sometimes be shortchanged when trying to stay on time in a busy office. Now, because of COVID-19, the need to be ever vigilant to ensure that thorough cleaning, disinfecting, and sterilizing is accomplished has never been more important, and achieving complete compliance with best practices in infection control cannot be over emphasized.
As part of a scientifically based profession relying on evidence-based research, dental hygienists appreciate concrete answers. The Centers for Disease Control and Prevention (CDC) is a research agency, but at the start of the pandemic there was a lack of research on a novel airborne virus. What was most challenging during the early stages of the pandemic was the lack of scientific information available. This was a new virus we were dealing with, and as findings became available the advice to comply with infection control protocols rapidly changed.
The basics of infection control have not changed, but we have added to the layers of defense used in our daily interactions with patients and these persistently mutating microscopic invaders. One enemy that hygienists have long been used to combating is aerosolization, but this took on new urgency in recent years as practitioners were suddenly thrust into new territory with the airborne SARS CoV-2 spreading around the planet, seemingly unstoppable. Air filtration and ventilation systems are now part of our arsenal in the battle to maintain a healthy environment. In addition, the level of filtration provided by facemasks has taken on more importance as we learn to live with COVID-19 and all its variations. At the beginning of the pandemic, fitted N95 and KN95 masks were scarce, and supply couldn't keep up with demand. When masks were in short supply, we followed protocols to sterilize, store, and reuse them. That is no longer permissible. Masks are now not to be reused.
Engineering and Work Practice Controls
Engineering controls remove or reduce the risk of exposure to harm through the use of products such as sharps containers, rubber dams, high-speed evacuation, and lead aprons. Rubber dams reduce aerosolization by isolating the treatment area from the rest of the mouth. High speed evacuation is now the standard of care when utilizing aerosol producing instruments such as ultrasonics.1 Reducing the amount of droplets that escape the oral cavity by suctioning a greater proportion released by this treatment modality is more important with this airborne virus. Developments such as Releaf and Purevac provide better evacuation for the hygienist working without an assistant.
Sharps containers provide the engineering control for safe injection practices. Aseptic techniques must be followed to ensure patient and provider safety when preparing syringes. Single-use vials, carpules, and needles should never be reused. Recapping using a device or the one-handed scoop method are techniques to be used when the patient may require additional anesthetic. If using a recapping device, remove the syringe from the device and lay it flat on the tray once the needle is safely covered. This will prevent accidentally tipping it over.2 All sharps must be disposed of in a puncture-proof designated sharps container located within the operatory.2 Sharps containers are part of regulated medical waste and must follow all state and federal guidelines for tracking and disposal.2
Work practice controls reduce the likelihood of exposure by changing the way a task is performed. Handwashing, the proper handling of contaminated items, and wearing appropriate PPE are examples of mitigating risks through commitment to following best practices while working in a potentially pathogenic environment. Handwashing is among the most important of all work practice controls.3 The most common method of disease transmission is through touch, yet very often little attention is paid to removing contaminated matter from our hands. Systematic, careful washing with an antimicrobial soap or alcohol-based disinfectant is necessary in preventing disease transmission.3
Wearing appropriate PPE while performing tasks that put health care professionals at risk for exposure is another work practice control that can easily be forgotten when time is of the essence. Not taking a few minutes to ensure safety is not worth the risk of contracting a debilitating illness.4One of the many shortcuts commonly used when in a time crunch is not wearing utility gloves when cleaning and disinfecting the treatment area. While many hygienists wear loupes while providing treatment, once the loupes come off and the room is prepared for the next patient, many forget to put on safety goggles. Goggles and masks are necessary during the spraying and wiping of contaminated surfaces. Removing these items prior to leaving the treatment area prevents cross contamination of non-treatment areas and provides protection for colleagues.
Engineering and work practice controls are part of standard precautions. What this means is that all protocols, policies, and procedures must be performed in the same way, every day, on every patient. Practicing as if every patient is infectious and has pathogenic blood and saliva that has the potential to infect every healthcare professional whom they come in contact with ensures that attention is paid to all precautions.
Cleaning, disinfecting, and sterilizing
Cleaning, disinfecting, and sterilizing are not all the same things. The differences lie in the degree to which pathogens are eliminated (see Table 1). Cleaning can be defined as the physical removal of surface debris and contaminants. It is accomplished mechanically. Disinfecting goes a step further by using chemicals to destroy some but not all pathogens. Sterilizing is the complete destruction of all microorganisms after removing all the debris.5
Surfaces in the treatment area that may be contacted directly through touch or indirectly through airborne transmission must be cleaned and then disinfected. Cleaning is effectively performed with the first wipe, and the second wipe is necessary to establish disinfecting. Wearing appropriate PPE during this process is imperative.5 Whatever EPA-registered hospital disinfectant is chosen, the first step is to clean the surface and then disinfect. The disinfecting agent needs to remain on the surface for the manufacturer's recommended optimal time.5 Dental offices typically use phenols, quaternary ammonium, alcohol, or sodium hypochlorite solutions for disinfection.5 In order to be EPA-approved agents must be effective against tuberculosis (TB), hepatitis B and C virus (HBV and HCV), human immunodeficiency virus (HIV), methicillin-resistant Staphylococcus aureas (MRSA), and SARS-CoV-2 (COVID-19).5 Additionally they must be broad spectrum bacteriocidal.5
To accomplish the goal of cleaning critical and semicritical items prior to sterilization, ultrasonic cleaners, instrument washers, and washer-disinfectors are used. Utilizing FDA-cleared automated devices improves the effectiveness of the cleaning and diminishes the risk of needlestick exposure. If there is still visible debris on an instrument, it must be removed before sterilizing. Utility gloves and a long-handled brush can be used, provided that the employee is wearing PPE to protect against splashing.
Following the manufacturer's instructions is key in ensuring the efficacy of sterilization. To validate the effectiveness of sterility, spore testing must be performed at least weekly.5 Logs of these tests need to be kept in order to comply with state and local regulations.5 The use of a control is important. At the conclusion of the spore test, the control should indicate growth while the sterilized tests should show no microscopic growth. This demonstrates that the vial contained active spores, and that the sterilizers used killed all active components. Sterile packages need to be stored so as not to compromise the sterility of the contents. Handling wet packages has the potential to cause wet pack wicking and draw microorganisms from hands into the sealed pack.6 Handling wet sterile packages may increase the incidence of corrosion on the instruments.6 Therefore all wraps should be allowed to fully dry before handling and storage.
Time, temperature, and pressure are the three elements that steam-under-pressure sterilizers rely on to completely eradicate all microorganisms. Following the manufacturer's instructions will reduce the number of cycle faults the machine announces. If a cycle fault is noted, the instruments are not sterile and may not be reused until processed successfully.6
The sterilization area should have a one-way flow so that contaminated instruments enter one way, and the work area flow follows a continuous pattern through disinfecting, drying, packaging, sterilizing, and storage. This establishes a pattern whereby it is difficult to confuse contaminated and sterilized instruments.5
Slow-speed handpieces connected to the unit through tubing must be sterilized between patients.7 The possibility of suck-back activity, even though not using water, means that these instruments require cleaning, disinfecting, and sterilizing the same way that the high-speed handpiece must be prepared for use on another patient. The risk of suck-back activity is extremely high when practitioners request that patients close their lips around the saliva ejector to evacuate excess moisture. Cordless hygiene handpieces may be wrapped and disinfected. Disposable prophy angles and barriers make this a more cost-effective piece of equipment.
Prior to wrapping or bagging contaminated instruments, they must be dried. Wet instruments reduce the integrity of the wrapping and increase the risk of needlestick injury.5 Hinged instruments must be opened so that the sterilization procedure reaches all aspects of the instrument. Anything that can be disassembled into its component parts should also be separated to ensure the sterility of all parts.5 Chemical indicators should be placed inside each package. If the packing material does not allow for the internal indicator to be seen, then an external indicator must be placed outside as well. Sterile packages need to be labeled as to the sterilizer used, the cycle number (located on the machine), and the date of sterilization.
Water Line Maintenance
Dental unit water lines are another area of concern to dental health care professionals. The EPA standards for drinking water are that there must be less than 500 colony forming units per milliliter.8 Dental treatment output water must conform to this standard.8 Testing kits are readily available at most retail home and hardware stores. Waterline treatment products to maintain this standard should be used according to manufacturer's directions. Protocol to protect the water lines includes purging the lines prior to periods of non-use, such as overnight. If the equipment experiences extended periods of inactivity, shocking the lines may become necessary to prevent stagnation of water within the tubing. A minimum of 20 to 30 seconds of discharging air and water from the unit between patients will help mitigate bacterial content within the lines.8 Products such as tablets inserted when water bottles are filled or the use of "straws" to disinfect the water are readily available. Manufacturer's instructions should be followed whichever method is chosen.
Establishing and Maintaining Best Practices
Administrative measures included in the CDC guidelines require that every facility have a written protocol outlining the steps to attain a safe environment. It requires an outcomes assessment overhaul of these policies and procedures at least once per year, or more often as changes become necessary.9 Every manual should have been revised to include mitigating the spread of COVID-19. An infection control officer, in charge of updating the manual and training all personnel as to these changes, is another requirement of compliance with CDC guidelines, along with maintaining training records.
Identifying potentially infectious employees and patients has been added to the daily routine, and screening for symptoms and raised temperatures has become the best defense to isolate the infectious among us.1
Guidelines for returning to work after testing positive for COVID-19 have recently been updated. April 5, 2022, saw the implementation of a national initiative known as "test to treat."10This program provides quick access to testing for the presence of COVID-19 virus, as well as access to treatment.10 Testing positive suggests isolation for five days. If the patient is asymptomatic and afebrile for 24 hours, a mask should be worn through day 10 of infection. After two negative antigen tests at least 24 hours apart, masks are no longer needed.10
The CDC has two levels of transmission used to determine what protocols should be in place in dental health care settings. "Community transmission refers to measures of the presence and spread of SARS-CoV-2. COVID-19 Community Levels place an emphasis on measures of the impact of COVID-19 in terms of hospitalizations and healthcare system strain, while accounting for transmission in the community."11 This is an important distinction because community levels can be low while at the same time transmission levels are high. It is the transmission level that should dictate the protocols in place.
An excellent resource for office use is "Summary of Infection Prevention Practices in Dental Settings." This publication is available at no cost through the CDC. It includes a checklist for observing current practices within the office (see Table 2). By indicating yes or no on the list, a plan for improvement can easily be implemented. Not sterilizing hygiene handpieces, not wearing utility gloves when processing instruments, handling and/or storing wet sterilized instruments, not covering ultrasonic units during use, and not utilizing protective eyewear for patients during procedures have been identified as problem areas needing improvement. A self-directed observation is a good tool to protect the staff and thereby protect the public from inadvertent transmission of infectious diseases.
Summary
To reduce the likelihood of exposure to COVID-19 and other pathogens, infection control protocols must be followed and updated. Carrying out proper cleaning, disinfecting, and sterilizing procedures and water line maintenance is as important as ever. Instruments must be properly processed before reuse. In addition, facilities must have an infection control officer and established written protocols, updated annually, to guard against transmission of harmful disease.
References
1. Centers for Disease Control and Prevention. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html. Version 2.3. September 2016. Accessed January 11, 2023.
2.Centers for Disease Control and Prevention. www.jointcommission.org/-/media/tjc/documents/resources/hai/hh_monograph.pdf. Accessed January 11, 2023.
4. Organization for Safety, Asepsis, and Prevention (OSAP) Knowledge Center www.osap.org/?page=KnowledgeCenter. Accessed January 11, 2023.
5. Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf. Updated May 2019. Accessed January 11, 2023.
6. Collins, FM. Wet Packs in Table-Top Autoclaves: A Common and Preventable Problem. tuttnauer.com/blog/wet-packs-table-top-autoclaves-common-and-preventable-problem. Updated August 18, 2020. Accessed January 11, 2023.
7. Kelsch N. Sterilizing handpieces. https://www.rdhmag.com/infection-control/article/16408601/sterilizing-handpieces. Updated Nov. 1, 2011. Accessed January 11, 2023.
8.American Dental Association. Dental Unit Water Lines: Guidelines for Practice Success | Managing Regulatory | Centers for Disease Control and Prevention. www.ada.org/resources/practice/legal-and-regulatory/04_dental-unit-water-lines. Accessed January 11, 2023.
9. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf. Updated May 2022. Accessed January 11, 2023.
10. American Dental Hygienists Association. COVID-19 Resource Center for Dental Hygienists. https://www.adha.org/covid19. Updated April 5, 2022. Accessed
January 11, 2023.
11. Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Updated Sept. 23, 2022. Accessed January 11, 2023.
