An Infection Preventionist’s Role in Dentistry: What Changes Need to Be Made

Close-up of the hands of a dentist and nurse surgeon over an operating room during a dental implant operation.

(Adobe Stock 314873958 by Валентина Баранова.)

Infection prevention (IP) doesn’t stop at the hospital door. One place where IP may be overlooked is in the dentist’s office. Infection Control Today (ICT) spoke to Amanda Hill BSDH, RDH, a registered dental hygienist and industry consultant, and Michelle Strange, MSDH, RDH, CDIPC, owner of Level Up Infection Prevention (www.levelupip.com) about why IP in dentistry is essential.

ICT: Why is IP important in dentistry?

Michelle Strange, MSDH, RDH, CDIPC: We all learn a little bit about IP and think we know it all. The industry is self-regulated, which is a bit dangerous, and…we all get very comfortable in our procedures and behaviors. We need to remember…how critical patient safety is and that we are doing these minisurgical procedures regularly. We are managing diseases in people’s mouths, periodontitis, wound management, [and] surgical extractions, and placing implants. These are all big things that need…optimum IP standards. Because we’re self-regulated, we need a role to hold us accountable because we’re human and will cut corners.

Dentistry IP is not mandated to have a specific type of training. However, the Organization for Safety, Asepsis, and Prevention (OSAP)¹ and many people who train infection control coordinators encourage additional education for this role. It [must be] somebody who is very detail-oriented and good with record keeping and continuing their education. It also needs to be somebody in the office with good communication skills because you become the “accountability sheriff” in practice. Coworkers shouldn’t feel they’re being chastised all the time or micromanaged, and you can meet people where they are while creating safe dental visits.

Amanda Hill, BSDH, RDH: The CDC says there should be an infection control coordinator,² [but they do] not say that the infection control coordinator needs specific training. Some states require yearly infection control training, but they don’t have any requirements about who gives that training. Infection control in dentistry is very different from medical infection control, where it’s somebody’s job. In dentistry, it’s an afterthought.

ICT: What specifics should an infection preventionist note when covering a dentist’s office?

AH: The CDC has an excellent free app called DentalCheck³ that tells you what to do. But there are fundamentals that I hope most offices are following—things like sterilizing our instruments. We must test our sterilizers once a week with the spore test. We’re also supposed to test our dental unit waterlines because bacteria can form in those, and people can get sick. The CDC recently issued a health advisory alert because [a] third cluster of children were sickened from contaminated dental procedure water.⁴ 

MS: When you think dentist…it’s “I just go to the dentist and get my teeth cleaned.” But when we use surgical tools on every single patient every single day, it’s important to think about the dentistry dental office as mini operatories with many nuances. It’s often a little difficult because we might, in one moment, be doing a dental cleaning, and then the next operatory, we are doing a surgical extraction. Those [procedures] are happening side by side. It feels like we’re just seeing patients, but in one, we need sterile water to ensure we have the proper infection control packaging [and] in another, we are using our dental unit waterline stuff and managing aerosols differently in that environment.… We often forget that we are doing big procedures in people’s mouths that are minor surgeries.

ICT: How does working in dentistry differ from working in a hospital?

AH: It shouldn’t be all that different. Contact surfaces would be about the same as the chair; anything that can get droplets or spatter is considered a clinical contact surface.

MS: What’s different for dentistry and what an IP needs to understand is that our turnover is very fast. We could use instruments from our 8 AM patient with our 4 PM patient, and our operatories get turned over very quickly. Many things can be missed. We start doing these things every hour on the hour, and we get comfortable. We must often be reminded that we can’t cut corners but must finish these tasks. We cut corners without even realizing we’re cutting corners. I understand turnover is much faster, and holding people accountable needs to happen more often.

ICT: What has changed since the COVID-19 pandemic, and what remains to be updated?

AH: Awareness has happened—everything we’re doing, we should have done before.

MS: More people are wearing the proper PPE [personal protective equipment]. As far as they know their mask level, the ASTM level, many are wearing respiratory respirators as they should be wearing face shields and surgical scrub caps. Because we create many aerosols, we all learned that our air quality in a dental office could be better. We have better ventilation, or at least people are working toward better ventilation in the operatories. And in the office, [individuals] were aware that they were not even doing the minimum standard of infection control practices, according to CDC guidelines. Many complained, “I can’t believe we have to do all these things,” whereas I said, “Why weren’t you doing that? These were standard precautions. These were not transmission-based precautions, …and if this is too much for you, we have a bigger problem.”

ICT: One specific thing is water quality and safety. What do infection preventionists look for in dentistry?

AH: …The aerosols we breathe in the aerosol-generating procedures come directly from our dental procedural water. That’s what you’re breathing all day long. What is in that water? It’s essential to test your lines periodically, the CDC says. OSAP recommends that you test monthly until you pass 2 consecutive times. And then you move to quarterly.¹ If you are testing and passing, you must have a system that keeps the biofilm down in your water lines. Water lines are tiny tubing, and the biofilm loves to grow in them, and then people get sick. It’s essential to have a system where you’re treating your lines with a low-level antimicrobial that can be a tablet, a straw, or a liquid.… And then you need to shock periodically, which means you put a higher-level disinfectant through those lines to wipe out the biofilm. But no matter what, you must test because you [have] to know whether whatever you’re doing is working or not working. It’s about the health of your patients and your team because it’s what they’re breathing.

ICT: Does anything tend to get overlooked?

MS: [I ask,] what are you doing to maintain your waterlines, test your waterlines, and follow the protocols. Then I would observe if they were running their waterlines before and between patients and ensure that everybody understands the “why” behind doing that.

AM: We often don’t use single-use items only once. Some people are thrifty all the time; they reuse things that should never be reused. We must be better about hand hygiene, whether hand washing or alcohol-based hand rubs. The other thing unique to dentistry [vs] medicine is that we need to stop seeing sick people. Wearing a mask doesn’t protect us from pathogens.

I would like to see more dental offices in the health care setting because they tend to have more rigorous protocols, guidelines, and demands around IP. I want to see our profession be better regulated and see more audits in dental offices. Patient safety is the foundation of care, and if we are not prioritizing that, we need to step back…and reassess. Because before you pick up a scaler or a drill or are ever allowed in the sterilization area,…patient safety is the first thing to consider. 

References

1. Organization for Safety, Asepsis, and Prevention. Accessed March 1, 2023. https://www.osap.org/
2. Standard precautions: summary of infection prevention practices in dental settings. CDC. Updated June 18, 2018. Accessed March 1, 2023. https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/standard-precautions.html
3. CDC DentalCheck mobile app. CDC. Updated December 7, 2021. Accessed March 1, 2023. https://www.cdc.gov/oralhealth/infectioncontrol/dentalcheck.html
4. Outbreaks of nontuberculous Mycobacteria infections highlight importance of maintaining and monitoring dental waterlines. CDC. October 31, 2022. Accessed March 4, 2023. https://emergency.cdc.gov/han/2022/han00478.asp