Ask Dr. Christensen: Do we need to change infection control?

Editor's note: In this monthly feature, Dr. Gordon Christensen addresses the most frequently asked questions from Dental Economics readers. If you would like to submit a question to Dr. Christensen, please send an email to [email protected].

This month's question

"As a mature general practitioner, I am concerned that the many confusing suggestions for infection control now being promoted because of COVID-19 may change dental practice infection control procedures significantly. I know that you have been practicing for a long time also, so what do you feel we should be changing in our infection control policies?"

Answer from Dr. Christensen

Our organizations—Clinicians Report Foundation (CR), previously named CRA, and the Technologies in Restoratives and Caries Research (TRAC Research) component of CR—have studied infection control actively since 1975. They have accumulated a large database of highly sophisticated research on the subject.

This research includes test data on more than 200 disinfectants sold worldwide, 20 brands of hand disinfectants, 60 dental face mask brands, innumerable brands of gloves, a dozen air-purification units, instrument disinfectants, sterilizers, sterilizer monitors, dental unit waterline disinfection, and other related items.

It is very frustrating to me to see that the research produced and published was not taken seriously by the government, manufacturers, or the dental and medical professions. If it had been, it is possible that some of the disease transmission problems we are now facing with COVID-19 would have been avoided.

The US government eliminated the National Testing Laboratory for disinfectants in the 1980s. Currently, the Environmental Protection Agency (EPA) and the Food and Drug Administration (FDA) specify tests and register disinfectants, but when a company wants to have a product listed by those agencies, the governmental organizations depend on research accomplished by commercial testing laboratories that the manufacturers themselves select and hire. The specified tests rarely have clinical relevance.

For example, as clinicians, we deal with patient fluids— such as saliva, blood, and other secretions—yet these are not required to be included in the test protocols for health care. Do I have to say more about this situation? It is apparent that nonbiased, clinically relevant research needs to be implemented today!

In this article, I will discuss several of the areas of infection control important to dentistry and offer my suggestions about needed changes, based on research and my clinical observations after many decades of practice.

The Centers for Disease Control and Prevention (CDC) has published a list of infection control recommendations for dentistry.¹ Unfortunately, guidelines like these are usually generic and never indicate the most effective brands of products. This implies to clinicians that all products function equally well, which is not true. Infection control in dental offices could be greatly improved in the US, and it is my candid opinion that this needs to happen immediately. However, you can quickly see that the infection control product companies whose products deliver poor results would object.

There are valid reasons why dentists often do not implement some of the CDC recommendations—they need critical observation, simplification, and potential revision.

First, it is common practice in dentistry to charge no patient fee for infection control procedures. It is assumed that this relatively complex and expensive set of procedures is included in the overall patient fees for preventive, surgical, and restorative treatment. The TRAC division of CR has recently estimated that infection control costs for one patient seating, using only one dentist and one assistant, costs at least $20. That amounts to hundreds of dollars per clinical day and many thousands of dollars per year.² Sharing the costs of infection control products and procedures with patients could motivate dentists to be more observant and thorough with their infection control policies and techniques. Billing the patient a separate fee for infection control spreads the financial burden, identifies that infection control is being accomplished, and should provide patients with confidence in the practice.

Second, some of the CDC recommendations require significant time, effort, and expense. It is a common comment from practitioners that these time-consuming concepts limit treatment when related to the number of operatories they have and the necessity to treat patients on a timely basis. These procedures need to be simplified as much as possible. They also need to be delegated only to well-educated staff members who understand why they are doing the procedures, how to do them properly, and which products best meet their expectations for use in the presence of the human proteins that are aerosolized, smeared, spattered, and spilled routinely in dental operatories.

Various infection control subjects are listed below with comments and suggestions about each. Details about all these topics are available in Clinicians Report (cliniciansreport.org) and Practical Clinical Courses (PCC) (pccdental.com) videos, courses, and the online International Study Club. [Note: The following information lists example products for each subject and is not intended to be a complete listing.] I suggest that you look over these items and evaluate your own infection control policies and procedures. Then, upgrade any you consider to be lacking.

Recommended vaccinations for health-care workers

Hepatitis B—three doses
Flu—one dose annually
MMR (measles, mumps, and rubella)—two doses of MMR four weeks apart
Varicella (chicken pox)—two doses four weeks apart
Tdap (tetanus, diphtheria, pertussis)—one-time dose and every 10 years thereafter
Observe these suggestions, particularly with staff, and enforce them in your practice.

Personal cleanliness

Handwashing
Chlorhexidine gluconate hand disinfectants 4% (Hibiclens or others)
Hand sanitizers (Purell or others)
Protective clinical attire that covers the clinician
Don’t come to work when you’re sick.

Treating sick patients

Don’t treat sick patients unless it is an emergency, and then use the same procedures now being suggested for COVID-19 patients.³
Many dentists and staff need to improve this situation.

Protective clothing

CDC recommends wearing gowns with a high neck and long sleeves (Landau Pocket Scrub Warm-Up, item no. 7551). Few dentists do this.
Inexpensive disposable gowns are readily available (Safewear). Few dentists wear them.
Scrubs are inappropriate for normal office attire.
Dentistry is negligent in this area and needs to improve.

Eye protection

CDC recommends solid side shields on glasses and loupes and/or a face shield (HSI Safety Shield).
Patient protective eyewear should be used (Googles Eye Shields, Rollens).
Our surveys show that most dentists adhere to these recommendations.

Face masks

Routine use on apparently healthy patients (Critical Cover PFL with Magic Arch, 3M Triple Layer Molded)
Suspect or visibly ill patients (Isolator Plus N95)
Make sure you select masks that seal adequately on the periphery.
Although most dentists have not been using N95 masks, their use will increase for some patients.

Gloves

For the last 25 years, dentists and physicians have been using gloves for routine procedures.
An important area in dentistry where negligence occurs is when exam gloves are used for surgical procedures.
Although more expensive than nonsterile exam gloves, surgical gloves should be used when doing surgical procedures (nitrile, e.g., NitriDerm; polychloroprene, e.g., Biogel).

Environmental surfaces

High ethyl alcohol solutions are well proven to kill bacteria and deactivate viruses.
Currently available, CR-proven products are BioSurf Bag-in-a-Box (84% ethyl alcohol by volume plus other ingredients) and LeCloth Wipes. Moisten the applicating wipe with disinfectant, clean the debris on the contaminated surface with the disinfectant-moistened wipe, let sit wet for three minutes to allow killing of microbes, and then repeat with a second application using the same steps.
Lysol has now reduced its ethyl alcohol content and requires up to nine minutes to disinfect surfaces.
Disinfectant wipes, although used widely, do not kill microbes well in the presence of ever-present patient secretions from aerosols, spatter, and spills.

Foot controls for water faucets, automated soap dispensers, and automated paper towel dispensers

Foot controls are readily available and highly recommended (Kohler). They eliminate touching constantly contaminated hand faucets.
Automated soap dispensers eliminate touching contaminated bottles of handwashing materials (enMotion).
Automated paper towel dispensers (enMotion)
Fortunately, most new dental offices have these features, but older ones often do not.

Air filtration

Airborne droplets are one of the most significant infection control problems in dentistry.
This subject is new to most dentists, and many manufacturers are working intently to study and develop adequate air filtration systems for dental offices. Be sure to shop carefully and ask for proof of claimed air clearance rates reported as particles per cubic foot by the specific room size.
CR is planning to compare many of the new systems currently coming onto the market.

Other items related to dental office infection control

Instrument disinfection
Sterilizers and monitoring
Unit water lines
CR will be conducting research on these items and others as time permits.

Summary

Infection control principles for dental practice have evolved significantly over the last 30 years, and major changes will again occur due to the COVID-19 challenge. This article has provided a discussion of some major areas of infection control that need to be upgraded. Evaluate your own practice’s protocols and procedures to see where change is needed.

Author’s note: The following educational materials from Practical Clinical Courses offer further resources on this topic for you and your staff.

New three-hour digital course featuring Rella Christensen, PhD

Preparing for Your Return to Dental Practice in the New COVID-19 World (item no. V2407)

One-hour videos

Infection Control for Every Practice (item no. V2452): This video includes information directly related to the Centers for Disease Control and Prevention recommendations and how to implement them.
Infection Control Techniques, Step-by-Step (item no. V2479): This is a classic video showing in detail the essential steps in aseptic technique for adequate infection control.

For more information about these educational products, call (800) 223-6569 or visit pccdental.com.

References

Guidance for dental settings: interim infection prevention and control guidance for dental settings during the COVID-19 response. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Centers for Disease Control and Prevention. Updated June 17, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html
Disposable infection control item costs (calculated for 1 clinician and 1 patient). CR Foundation. April 21, 2020. https://www.cliniciansreport.org/uploads/files/1877/PPE-costs-per-patient.pdf
COVID-19: updated and latest dental implications and solutions. CR Foundation. Clinicians Report. 2020;13(5):1-3.

Gordon J. Christensen, DDS, PhD, MSD, is a practicing prosthodontist in Provo, Utah. He is the founder and CEO of Practical Clinical Courses, an international continuing education organization founded in 1981 for dental professionals. Dr. Christensen is cofounder along with his wife, Rella Christensen, PhD, RDH, and CEO of Clinicians Report.

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