Reflections on HTM 01-05
Bob Newsome discusses decontamination with Martin Fulford.
What contribution has HTM 01-05 made to decontamination in dental practices?
I think its contribution has been positive and timely. At the time it was first published, dentists needed a document around infection control that had detail, but which was also easy to follow. Its original intention was to narrow the gap between good practice and ‘less’ good.
Did it succeed in that?
No, I think it failed. My personal view is that rather than narrowing the gap, it actually grew – the good got very good and the bad got a little bit better. The less good practices did just enough to comply. Whereas the good practices went the extra mile.
Do you think HTM01-05 fulfilled its remit in terms of the amount of detail it contains?
Yes, I do. Overall, I think it’s a good document but it does lack an evidence base in parts, mainly due to the fact that the evidence simply isn’t available, therefore the advice has been based, in most cases, on scientific and engineering principles.
HTM01-05 was published 2009 and marginally revised in 2013. Is now the time to look at it again?
I think there are some anomalies in the document in that it has two standards. The essential standard that you have to achieve, and then ‘best practice’. Now is the time for us to work to a single standard, as happens in Scotland. The original intention was that practices achieving the essential standard would have in place a plan that would describe their journey towards best practice, but in reality this simply hasn’t happened, nor has it been enforced.
Do you think the introduction of washer-disinfectors should be mandatory as they are in Scotland?
Yes! Washer-disinfectors provide the only method of cleaning instruments consistently and therefore is the only one which can be properly validated. The effective cleaning of instruments is an absolute prerequisite for achieving sterilisation. If you don’t clean instruments thoroughly then sterilisation is likely to fail. The use of washer-disinfectors also makes instrument cleaning much safer for practice staff, as it reduces the risk of acquiring a sharps injury.
Is a washer-disinfector a better option than an ultrasonic bath?
The problem with ultrasonic cleaning is that the majority of practices reuse the same solution for cleaning successive batches of instruments. HTM01-05 says the cleaning solution should be changed at the end of each clinical session, i.e. lunchtime and at the end of the day. In theory, the first batch of instruments processed are fine, but the last batch…?
In my lectures, I use the analogy of a modern family with a toddler being toilet trained. Obviously, if the toddler soils itself, it’s put in the bath and the excrement washed off – but would the family then get into the same bath? A bit extreme, but it gets the point across!
What would the reaction of the profession be to the introduction of mandatory washer-disinfectors?
Well, I suspect there would be an outcry on several levels. Washer-disinfectors have come a long way from the first generation which were little more than domestic dishwashers. Now there are some that are purpose designed and built, and benchtop versions are ideal where space is at a premium and cost, both capital and revenue, is also an issue. They have a finite lifespan in terms of technology and also mechanically. Therefore, practice owners need to have a renewal plan, which should be part of their business plan. Like autoclaves, it’s really essential to have more than one, because you can’t rely on one machine performing day after day. At some point, it will break down, meaning that without backup the practice would have to close and face the economic consequences.
When it comes to Dental Unit Water Lines (DUWLs), many practices don’t address the issue of biofilm contamination, and those that do tackle the problem do so in several different ways. How big a problem do you think this is for dentistry?
It’s a bigger problem than we recognise. HTM01-05 advice around DUWLs is poor and is not evidence based, despite the fact that published evidence is available. If we take the advice to flush the water line between each patient as an example, external evidence suggests that this is ineffective, so why is it in the guidance? In fact, the biggest risk around contaminated DUWLs is to dental staff rather than patients. Caroline Pankhurst, Senior Specialist Clinical Teacher at King’s College London, has written an article speculating that late-onset of asthma, which is more prevalent in the dental profession that in the general population, could be caused by occupational exposure to contaminated DUWLs. There has also been a report published implicating the death of a dentist from Legionella infection with a contaminated DUWL.
Are there other aspects of HTM01-05 that you would like to see improved?
The processing of handpieces is a part of HTM01-05 which is extremely poor. However, I’m not convinced there’s a large enough body of evidence available to improve the guidance. The problem is we don’t know how much contamination gets inside a handpiece, and I suspect evidence would vary between manufacturers. There is specific equipment available for cleaning the inside of handpieces and, as I said previously, you have to get the cleaning right for sterilisation to be effective. In terms of sterilising a handpiece, as it’s a hollow instrument it should be sterilised in a vacuum autoclave, but the majority of practices don’t have these, so how are we sterilising adequately?
Manufacturers have a responsibility to ensure that their equipment comes with appropriate validated instructions on reprocessing, but we know this isn’t the case. A paper written by Andy Smith and his colleagues in Glasgow looked at a wide selection of dental instruments and how they complied with the EN requirement to provide proper validated instruction. The results showed that about 90% of products on the market didn’t comply.
So every handpiece sold should come with validated instructions on how to reprocess it?
Yes. Every probe, mirror, every instrument should be the same. It’s the MRHA’s responsibility to enforce this, and I believe that a single prosecution on this matter would improve compliance overnight. Ironically, HTM01-05’s default position is ‘follow the manufacturer’s instructions’. Sadly, the manufacturers don’t always provide such instructions, nor validated guidance on how to reprocess, so dentists are being poorly served in this respect.
In terms of the future, are there any plans to amend HTM01-05?
We were told when it was published that it was a ‘live document’, i.e. it would be subject to amendments when more research was available to improve the advice. We saw that in 2013. Now we are another four years on but the CDO has an extremely full in-tray. I hope that in the foreseeable future this will rise to the top of the tray and become a task that is prioritised.
Would your main wish be the implementation of a single standard?
It would be extremely helpful and less confusing if a single standard approach were adopted, but I know this would also present challenges for the profession. Scotland published their guidance in 2007 and there were some big problems around implementation, but it was backed by financial assistance. If we fast-forward 10 years, hands up all those who think the DH has money to throw at dentistry? I understand the pragmatism about trying to improve standards, but I really believe the time has come for the next step.
How do you convince dentists that infection control is an investment in their business?
The problem is that good infection control is a cost with no apparent financial return. But, the truth is that having a dedicated decontamination area and team frees up clinical staff to do clinical jobs and these do generate income. If a dental nurse could be chairside instead of decontaminating instruments, the dentist could treat more patients. If we start to think strategically about infection control and understand it can be efficient and effective and lead to improvements in working conditions for clinical staff, then it suddenly becomes a topic that practices can shout about to their patients. My advice is always the same: if you’re doing it well, tell everyone – don’t hide it, as it can be a practice builder!