Holly Dickinson, Business Development Manager at Dentisan.
Learning outcomes
- To educate readers about the importance of documentation and record keeping in the dental environment.
- To give readers an understanding of the legal requirements relating to infection control.
- To teach readers about routes of infection and the risks microorganisms pose to patients and staff in the surgery environment.
This article meets the criteria of the GDC’s development outcomes for enhanced CPD in category C
It is well-known by dental professionals that compliance with infection prevention and control measures within practice settings is essential to minimise the risk of infection transmission. It is also known that an understanding of the reasons why particular infection control protocols must be followed helps to increase levels of compliance.
Modern infection control requires considerable administration and record keeping. It also requires an understanding of the legal requirements around infection control, as well as knowledge of the risks microorganisms pose to patients and staff in a surgery environment.
Guidance and regulatory documents
Guidance is in place as a legal requirement, not just to ensure the best possible standards are maintained for patients, but also to protect members of the dental team should potential issues arise. There are several guidance documents relating to infection control, including HTM 01-05 (England) and SDCEP (Scotland).
The Care Quality Commission (CQC) is the statutory regulator for dental care services in England and practices must be registered with the CQC in order to provide regulated activities. The CQC has far-reaching powers to take action against dental practices that do not meet fundamental standards, including those in relation to infection control and record-keeping. Failure to meet the standards can result in censure, fines, or in the worst cases, closure of the dental practice[i].
The main risk factors associated with infection control are:
- Infection / illness / death of a patient
- Litigation
- Failure of a practice inspection
- Negative press
- Erasure from the GDC (General Dental Council) register
Administration and paperwork
To ensure standards of service are being implemented, records and procedures must be in place to demonstrate that regulations are being met. These include:
- A designated infection control lead
- An IPS Audit every six months to ensure infection control measures are adhered to by practice staff
- Hand hygiene audit
- Full written infection control protocol
- Immunisation records to ensure all members of the dental team are protected against diseases including diphtheria, hepatitis C, polio, measles, mumps and rubella (MMR).
- Staff induction records
- Staff CPD records as an important part of maintaining GDC registration
- Instrument decontamination records
Dedicated log books provide the required record keeping for a full year of safety checks and tests for autoclaves, washer disinfectors and ultrasonic cleaners. This is a convenient way for infection control leads and those responsible to complete necessary audits of compliance, and to log faults and repair records.
According to HTM 01-05 section 2.23: ‘Audit documents should be stored for at least two years. They should not be removed from the premises or destroyed.’
Illness, infection and microbiology
Pathogens are the first link in the chain of infection and the main pathogens of concern within dentistry are bacteria, fungi, viruses and prions. The very nature of dental procedures means members of the dental team can come into direct contact with pathogens, especially those found in blood and saliva.
Amongst the most serious of these are blood-borne viruses that cause hepatitis B and C, which can be readily transmitted from an infected patient to members of the clinical team via accidental punctures to the skin from blood-contaminated needles, scalpels or other sharps.
It is estimated that (257,000) 0.5-1% of the UK’s population are chronically infected with hepatitis C, with around 80% of infections without symptoms making it likely infected individuals are unaware of their infected status[ii]. Approximately 0.1-0.5% of the UK suffer with hepatitis B, usually acquired in adulthood through sexual activity or intravenous drug misuse[iii].
Bacteria, fungi, viruses and prions are not visible to the naked eye. However, just because they cannot be seen, it doesn’t mean they are not there. Patients attending the practice with a cold, for example, can easily spread that virus by hand, which comes into contact with surfaces such as the reception desk or doorknobs, posing a possible, yet invisible infection risk to the next person who touches them.
The simplest way to break the routes of infection is with thorough cleaning and disinfection of work surfaces after every patient with products that have proven efficacy against mycobacteria (including TB), bacteria, fungi, yeast and all enveloped viruses such as coronaviruses, hepatitis B and C and HIV.
What are the risks?
- Bacteria are responsible for infections including styes and boils, sore throats, pneumonia, sepsis, MRSA, TB and Legionella.
- Oral infections caused by fungi are commonly found in children, elderly patients and denture wearers and are responsible for infections including oral thrush and Candida albicans.
- Viruses include coronaviruses, hepatitis B and C, influenza, HIV, herpes simplex and norovirus.
These can all be eradicated through thorough cleaning, disinfection and sterilisation.
Prions, however, are inanimate objects – naturally occurring proteins with abnormal folding. Prions are proteinaceous infectious particles responsible for transmissible spongiform encephalopathies (TSEs), rare but fatal neurodegenerative diseases affecting humans and animals. Prions must therefore be physically removed through cleaning and disinfection.
Effective cleaning is essential to enable the sterilisation of instruments to be carried out reliably. Any organic material or adherent dental materials left on instruments can inhibit those processes[iv].
Another potential infection route, where pathogens can reside and multiply, is within dental unit waterlines (DUWLs). The quality of DUWL output water entering a patient’s mouth is only as good as the quality of the input water, and both supplies should be regularly tested and results logged to ensure compliance.
Bacteria detected in the output water could indicate the presence of biofilm that readily builds up in the narrow tubing of DUWLs. To maintain water quality it is important to treat DUWLs on a weekly basis with a proven, commercially available disinfectant. Dip slides can also be routinely used to check for contamination in dental water systems.
Surgical uniforms should also be part of a practice’s health and safety policy. Uniforms can become contaminated with microorganisms during clinical procedures and therefore should not be worn outside the practice. Department of Health (2010) guidance on laundering uniforms states that washing with detergents at 30°C will remove most Gram-positive microorganisms, including MSRA. It advises that a 10-minute wash at 60°C is sufficient to remove almost all microorganisms[v]. Under DH (2010) and HTM 01-05 guidance, uniforms should be washed separately from other household laundry, and washed at the hottest temperature suitable for the fabric to reduce any potential microbial contamination[vi].
Knowledge is power
Thorough cleaning, disinfection and sterilisation are vital elements in reducing the risk of infection transmission. By having a greater understanding of the transmission routes of infections and the risks posed to patients and staff, dental teams are better placed to take appropriate action and complete the necessary audits to ensure documented compliance.
[i] https://www.dental-nursing.co.uk/features/cqc-and-you
[ii] Ref Gov.uk 2022
[iii] Ref Gov.uk 2022
[iv] SDCEP Cleaning of Dental Instruments, Dental Clinical Guidelines. March 2007.
[v] https://www.dental-nursing.co.uk/features/professional-responsibilities-around-uniforms-and-ppe
[vi] HTM 01-05 (2013) Section 6.35
