Th 161303

Respiratory etiquette: Is there a place in dentistry?

Sept. 1, 2004
Ayear ago as I sat in the waiting room to be called for my own dental appointment, I overheard a request by a walk-in patient to obtain some masks for his wife and himself.

A year ago as I sat in the waiting room to be called for my own dental appointment, I overheard a request by a walk-in patient to obtain some masks for his wife and himself. In a few days, they were boarding an airplane for a seven-hour flight to Hawaii and were very concerned about the potential exposure to SARS (severe acute respiratory syndrome) while in the plane. The dentist happened to enter the office and heard this request, gave a chuckle, and turned to me for advice. Needless to say, I seized the opportunity to enlighten the gathered persons that prevention and protection are the two best defenses against disease and gave instructions regarding handwashing and mask wear. The dentist provided several surgical masks to the man as well as a bon voyage. Here is an example of an informed patient, who actively employs preventive measures to safeguard his health and that of his family.

The reemergence of SARS and avian influenza H5N1, along with seasonal influenza, have prompted everyone to refocus on prevention and protection modes of operation. While the peak influenza period may be waning, the ever-changing weather makes transmission opportunities for viral respiratory illnesses real and serious. Heightened awareness from World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) is based on the reported cases of SARS and avian influenza in the Orient. The reported morbidity and mortality associated with this season’s influenza has resulted in a late rush for flu vaccine, yet when the supply is decreasing. A crisis reaction by patients everywhere can only further frustrate healthcare workers, who have advocated early immunization in October for protection against influenza, but had less than 100 percent compliance. Especially disheartening is the mortality reports of patients with nosocomial or hospital-acquired influenza as a result of refusal by healthcare personnel to have their annual required influenza immunization. Some would classify this occurrence as a sentinel event due to willful non-compliance.

So does this all have relevance to the dental arena? Yes. Patients present for dental care daily and bring with them other acute, episodic, and chronic medical conditions. Screening mechanisms in the dental office range from visual assessment to completion of a health screening questionnaire or similar tool. When reviewed by the dental team, other inquiries may be necessary to ensure safe procedure with the scheduled and/or requested dental care. If no updated screening is accomplished on this dental visit, then the dental team may be placing themselves at risk for exposure and/or illness. This, in turn, can result in exposure to other patients during the day and in the office. This pre-dental phase of care may necessitate re-evaluation for astute assessment.

One of the new initiatives to confront the reemergence of respiratory illnesses is the CDC “Cover your cough” campaign. This is a new preventive strategy involving signage, supplies, segregation, and survey. Basically, the associated “Cover your cough” poster simply states that persons with a cough should cover their nose and mouth with a tissue when coughing or alternatively cough into their shirt sleeve. While the latter is less than hygienic, it is a containment of aerosols by the unprepared person. The contaminated tissue is disposed of in the wastebasket and hands are immediately washed. This new strategy may have a familiar ring to it - something Mom said a million times when we were children with the sniffles. Still makes sense today, but sadly is not practiced as routinely as basic hygiene and consideration for others would dictate. So if you have visited a medical clinic or the emergency room recently, you probably have seen the poster as a form of screening at the reception or access point. There are surgical masks, Kleenex tissue, and handwashing facilities and/or alcohol handrub available for your use. Additionally, you are asked about recent travel to the Orient and told to sit in a separate area from the non-contagious waiting patients. A nurse is notified and you are further assessed and possibly placed in isolation before encountering the physician. Once the diagnosis is made and confirmed and the disease is a reportable disease, report the occurrence to the Public Health Department.

Some healthcare facilities have modified the “Cover your cough” initiative to Respiratory Etiquette. Respiratory Etiquette is applicable everywhere people gather and has all the same elements of the CDC campaign. The rationale behind Respiratory Etiquette is that it more widely applies to any dissemination of microbial droplets likely to transmit infectious diseases to others. The infection prevention principle is to contain and confine, meaning contain the distribution of germs to the three-foot perimeter (confine) of the person. Limiting transmission and capturing the germs in tissue are active interruptions of disease spread. Again, this is basic hygiene.

Respiratory Etiquette can and should be practiced in the dental arena. The dental team is in much closer proximity to the patient and his or her respiratory tract than most healthcare personnel. Wearing a mask for each patient encounter is standard dental practice as a result of the 1991 Bloodborne Pathogen Rule. Washing hands after glove removal, changing masks per each patient, and washing hands before donning fresh gloves are also integral to the implementation of the Final Rule.

So the barrier protections are in place; but what about the immunization component? Is an annual influenza vaccination a requirement for dental personnel, especially in private dental office practice settings? Where would this immunization be obtained? Is there a monitoring mechanism in place? What are the consequences if personnel choose not to comply? Besides, there are no reported cases of SARS, avian influenza, or seasonal influenza linked to dental practice; so why would it even be entertained as a preventive safeguard in dentistry? All are valid questions and relate to the bottom line: Who pays for this?

Like other preventive strategies suggested and mandated by federal agencies and other licensing bodies, the dentist in private practice may meet the “exception to the rule” criteria and brush this one aside as well. His or her rationale may be that his or her pre-dental assessment phase already is thorough in obtaining updated medical histories on patients and rescheduling patients with contagious conditions until they are better. Or the dentist may justify his or her exclusion of this new initiative based on the beneficiary population served, who are not at risk for these diseases, or some other reason. The choice remains the decision and responsibility of the practitioner and/or the facility. So whether dentistry senses any benefit to support and practice this new initiative in infection prevention remains unknown. It is worth a consideration and may safeguard you and your staff.

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Nancy Bjerke is an independent consultant with Infection Control Associates, providing consultation services to diverse healthcare practice settings, industry, and professional organizations. Nancy has presented posters and oral presentations at local, state, and international Infection Control conferences. She serves on various organizational committees, advisory boards, and task forces as well as held elected positions in APIC, CBIC, AORN, and TSICP. She maintains membership in AORN, APIC, TSICP, and Organization for Safety and Asepsis Procedures (OSAP). She can be reached by e-mail at [email protected].