Possible disease outbreak in dental clinics validates the need for infection-control protocols

Aug. 25, 2010
Two recent events brought national attention to infection control in dentistry. Breaches in infection control remind us that we must have protocols for instrument processing and be sure that everyone is following the same routine.

By Leslie Canham, CDA, RDA

Two recent events brought national attention to infection control in dentistry. The first case was in West Virginia during a two-day “Mission of Mercy” dental clinic held at a high school in June of 2009. Three patients and two clinic volunteers were identified as having acute hepatitis B infection. County, state, and federal agencies have been working to determine how they contracted the disease.

There is laboratory evidence that weaknesses in infection control have been identified. The clinic was held in a temporary dental setting, and investigation suggested that some of the equipment was not cleaned properly or was not functioning correctly. In addition, there was no infection preventionist involved in the clinic setting and operations. An infection preventionist is an expert who specializes in preventing infection in health-care settings.

As a result of the hepatitis B infections, notification letters were mailed to 1,137 patients and 826 volunteers. The letters recommended testing for hepatitis B, hepatitis C, and human immunodeficiency virus (HIV).

The second event was the dental clinic at John Cochran Veterans Administration Medical Center (VAMC) in St. Louis. Dr. Gina Michael, a spokesperson for VAMC, said that the dental instruments were sterilized but the proper sequence of instrument processing was not followed. It was determined during an audit that the breach in protocol for instrument processing took place from February 2009 to March 2010. Because the VAMC could not determine that the risk to patients was zero, 1,800 patients were notified that they could have been exposed to hepatitis B, hepatitis C, or HIV. Patients were also offered testing, evaluation, and counseling.

What happened? The dental instruments at the VAMC dental clinic were supposed to go directly from the dental clinic to a central sterilization room. In the central sterilization room, the instruments were to be placed in an instrument washer, placed in sterilization wrap, then placed in the sterilizer. Instead, the instruments were hand scrubbed by the dental assistants in a sink in the dental clinic, dried, wrapped, and then sterilized.

Dental instruments can be cleaned by hand scrubbing or by automated processes. However, the VAMC audit revealed that its policy of placing instruments in an instrument washer was not followed. As a result of the breach in their protocol, VAMC could not be 100% sure that every instrument used in each patient’s mouth was perfectly clean.

Cleaning instruments is the most important step in instrument processing

Cleaning should precede all disinfection and sterilization processes. It should involve removal of debris as well as organic and inorganic contamination. Removal of debris and contamination is achieved either by scrubbing with a surfactant, detergent, and water, or by an automated process (e.g., ultrasonic cleaner or washer-disinfector) using chemical agents. If visible debris, whether inorganic or organic, is not removed, it will interfere with microbial inactivation and compromise the disinfection or sterilization process.

Considerations in selecting cleaning methods and equipment include:

  1. Efficacy of the method, process, and equipment
  2. Compatibility with items to be cleaned
  3. Occupational health and exposure risks

Use of automated cleaning equipment (e.g., ultrasonic cleaner or washer-disinfector) does not require presoaking or scrubbing of instruments and can increase productivity, improve cleaning effectiveness, and decrease worker exposure to blood and bodily fluids. Thus, using automated equipment can be safer and more efficient than manually cleaning contaminated instruments.1

These breaches in infection control remind us that we must have protocols for instrument processing and be sure that everyone is following the same routine. Even well-intentioned dental workers can make grave errors or omissions in infection control that can cause an infection-control disaster. You can reduce the risk of infection transmission by receiving ongoing training in infection control, conducting periodic audits of your dental office’s procedures for instrument processing, and having your infection-control protocols in writing. When it comes to patient safety, infection control is in your hands.

To receive a complimentary copy of an Instrument Processing Protocol checklist, send an e-mail to [email protected].

Author bio
Leslie Canham is a dental speaker and consultant specializing in infection control and OSHA compliance. She has more than 36 years of experience in dentistry. Canham is the founder of Leslie Canham Seminars, providing in-office training, mock inspections, consulting, and online seminars and webinars to help the dental team navigate state and federal regulations. Reach Canham at (888) 853-7543 or Leslie Canham.

1 Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings 2003. MMWR 2003; 52(RR-17):21.