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Disclosure: The author had no disclosures to report.
Whether you’re a manager of a dental laboratory or an owner, you must understand the absolute importance of infection control practices. The Centers for Disease Control (CDC) recommends that health care employers, including dental laboratories, appoint an Infection Prevention Coordinator (IPC). The IPC’s role is to identify and develop infection prevention practices for protecting employees and people they come into contact with while providing services outside the laboratory (such as picking up cases or assisting chairside). Using established steps, each coordinator should develop an effective safety program by identifying potential hazards, establishing infection prevention practices, training employees on best practices, and monitoring ongoing compliance. As with any safety program, the effectiveness of each step will depend on commitment from the top and consistent enforcement.
For the protection of workers from potentially infectious items, the Occupational Safety and Health Administration (OSHA) published the Bloodborne Pathogen Standard3 (BPS) in 1992. This standard directs employers to assess their workplace to determine the job classifications of workers who could be exposed to potentially infectious items. The BPS identifies some specific areas of concern, but does not provide, in most cases, the details on how to protect workers. This is where employers must look to other reliable resources to develop good infection prevention practices. The CDC guidelines from 20031 and 20162 offer the most recognized practices available and are used in this course to help the IPC carry out the responsibilities of their role.
Identifying Hazards in the Dental Laboratory
The IPC in a dental laboratory must consider certain risk areas in order to identify potential hazards to its employees, not only in the laboratory itself, but also in a dentist’s office performing chairside services. Picking up cases from dental offices, bringing them into the laboratory, and disinfecting tools and materials for processing are riskier in terms of exposure. The manipulation of impressions when trimming back over-extended borders on impressions also introduces the possibility of contamination, as does the presence of blood in some implant components and repairing and relining dentures.
Many of the risk areas indicated above exist in most dental laboratories, but technology is changing dentistry and affecting infection control practices as well. The scope of services provided by dental technicians to dentists has expanded significantly and now can include chairside services. The result appears to be the development of stronger relationships between dental technicians and their dental clients. This expansion of services, however, means that dentists need to consider protection of dental technicians when in the clinical environment. Likewise, the dental practice must assess any exposure this could contribute to patient safety.
Chairside assistance can include:
• Set-ups—implant and conventional
• Scanning of crown-and-bridge cases, providing a crown—same-day concept
• Guidance on implants
• Consulting capacity
• Intraoral verification
• Immediate conversion
The IPC must identify the hazards to their employees such as when they are in a dental practice working with or near patients and individuals accompanying patients who are sick. One important aspect of this is managing chairside services provided by dental technicians and other auxiliary staff. Properly disinfecting and sterilizing dirty instruments, handling and disposing of sharps such as needles, and cleaning patient treatment rooms and sterilization areas are all tasks where technicians are exposed to risk and therefore the IPC must consider.
For both the laboratory and the dentist’s office, the best method of identifying the risk areas is to ask employees where they encounter blood and saliva. There may be areas that aren’t identified above, so a diligent effort to identify them all is critical to following through with the next steps.
Establishing Infection Prevention Practices
All dental settings, regardless of the level of care provided, must make infection prevention a priority and should be equipped to observe Standard Precautions and other infection prevention recommendations that are contained in the CDC’s Guidelines. For both laboratories and offices, the employer should refer to the BPS and CDC for guidelines when establishing infection control practices. The practices chosen must be specific to the work environment in order to protect workers.
Training Employees on the Safety Practices
The breakdown of basic infection prevention procedures reported by the CDC in the Summary highlight the need for comprehensive training. Making sure the employees understand why these conditions should be met, to minimize and/or eliminate disease transmission, can improve adherence. A written safety program must provide effective training in order to ensure employees understand how to protect themselves using the controls established by the employer. Remember, OSHA requires businesses to be able to show that training has been conducted, so be sure to document any safety training.
Monitoring Compliance with the Practices
This section brings us to the main focus of this course, which is the role that the IPC plays in monitoring compliance with infection prevention practices in their workplace. The 2016 CDC Summary recommends that the IPC be responsible for developing written infection prevention policies and procedures based on evidence-based guidelines, regulations, or standards. These policies and procedures must be tailored to their workplace, must be reassessed on a regular basis, and should also consider the types of services that are provided in the laboratory or another workplace and to the patient population served. The IPC should ensure that equipment and supplies—such as hand hygiene products, safer devices to reduce percutaneous injuries, and personal protective equipment—are available. Of course, the IPC should maintain communication with all employees to address specific issues or concerns related to infection prevention.
Additionally, the CDC points out in the 2016 CDC Summary guide that infection prevention practices should include policies and protocols for early detection and management of potentially infectious persons at initial points of patient encounter. This can apply to the dental laboratory employees as well as dental staff in the dental practice.
The guide recommends, at a minimum, that certain prevention methods be assessed annually. However, more frequent monitoring is beneficial because it provides immediate recognition of unsafe practices so they can be corrected and training provided where necessary. It also provides an opportunity for better communication if the practices were not understood when introduced.
Appendix A of the Summary provides a checklist that can be used by the IPC. The IPC needs to take that information and incorporate the infection prevention practices that are relevant to the workplace into that template checklist. This offers the IPC a useful tool to assess how the employees are observing the practices during performance of their duties. The following is a snapshot of the Section I checklist, along with notes on how the section applies to infection prevention practices in the dental laboratory and, for chairside services, the dental practice.
First, administrative measures in the checklist include evaluating the written infection prevention policies and procedures. The IPC should watch for indications that the written information may be outdated so that they can be updated appropriately. It’s also critical to get training for the IPC if practices have changed, along with requiring training for any employees who are not following the practices. Another important administrative responsibility is ensuring that materials and supplies are available in order to practice standard precautions. This can include hand hygiene products, safer devices, and personal protective equipment. Handling potentially infectious persons who enter the facility, and making everyone aware of good respiratory hygiene and coughing etiquette, are all parts of this measure.
Infection prevention education and training mean giving employees job-specific instruction on relevant policies and procedures upon hire, when new tasks enter the workplace, and annually. It should also involve meeting any state or federal requirements for safety training. For instance, in some states, dentists and certain staff members may be required to receive a certain number of hours of infection control training as a part of their licensing requirements. Certified Dental Technicians must receive 1 hour of regulatory standards continuing education credit each year, which can include infection control training.
Hand hygiene is the most basic requirement, and handwashing is considered the cornerstone of infection control. Therefore, it’s important that supplies such as soap, water, paper towels or dryers, and even alcohol-based hand sanitizers are readily accessible in the work areas. If adherence is an issue, it’s advisable to have training on the use of these supplies and methods of handwashing.4
The IPC should also be aware of the need to guarantee availability of the appropriate personal protective equipment (PPE) for any tasks required of employees. If they’re not well versed on the proper selection and use of PPE, the IPC should undergo training.
Respiratory hygiene or “cough etiquette” is another important part of infection prevention inside and outside the laboratory. It includes:
• Reviewing the written policies and procedures established to contain respiratory secretions in potentially infectious persons who enter the workplace.
• Posting signs at entrances and employee areas to use good coughing etiquette. The CDC’s web site provides number of signs for employer use.5
• Providing tissues and face masks to patients and employees as needed.
• Training employees on how to contain respiratory secretions in patients and/or employees who show signs and symptoms of a respiratory infection.
Sharps in the dental laboratory can include utility knives and tools used to trim back impressions since it’s not unusual for blood to be exposed inside the impression during this procedure. Sharps safety includes reviewing written guidelines established by the employer for exposure prevention and post-exposure management, monitoring sharps injuries, and evaluating cause and prevention techniques needed at least annually. It also means that the IPC should evaluate and select devices that have engineered safety features when practical. Of course, safe practices for the use of needles and disposal of needles in the dental practice are critical to the safety of dentists, dental staff, and any chairside technicians during patient treatment.
While it’s unusual to see sterilization being performed in a dental laboratory, it is required on all potentially infectious items. Sterilization and disinfection of patient-care items and devices entails ensuring that dental staff is trained on proper reprocessing of reusable dental instruments and devices which includes the use of PPE. It is critical to confirm that the correct sterilization or disinfection process is being used on devices that need it. It’s also important to verify that sterilization equipment is being maintained according to the manufacturer’s instructions and documented.
Lastly, it’s important to verify that dental unit water quality meets the Environmental Protection Agency (EPA) regulatory standards for drinking water. When appropriate, assess the use of sterile water.
In summary, use the information that is presented in the CDC’s 2016 Summary Guide and the 2003 CDC Guidelines for Infection Control in Dental Health-Care Settings as guidelines for your laboratory’s infection prevention practices. As stated above, the first step is to assess the laboratory’s potential risks and ensure that there are written infection prevention practices and procedures that address the specific risks in your workplace. Use the CDC’s checklist guidelines to produce your own checklist. Establish a recommended monthly schedule for monitoring the infection prevention practices and noting areas for improvement. The results of the IPC’s assessments should be used to determine where additional training is needed or when practices and procedures need to be updated.
1. Guidelines for Infection Control in Dental Health-Care Settings. Centers for Disease Control web site. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Accessed May 15, 2017.
2. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. 1st ed. Available at: www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care.pdf. Accessed May 15, 2017.
3. Bloodborne pathogens. Occupational Safety and Health Administration web site. Available at: www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051. Accessed May 15, 2017.
4. Posters Handwashing. Centers for Disease Control web site. Available at: www.cdc.gov/handwashing/posters.html. Accessed May 15, 2017.
5. Cover Your Cough Seasonal Influenza (Flu). Centers for Disease Control web site. Available at: www.cdc.gov/flu/protect/covercough.htm. Accessed May 15, 2017.
About the Author
Mary A. Borg-Bartlett
SafeLink Consulting, Inc.