Infection Control

Please note: this article is taken from the 2005 Australian Dento-Legal Review.

Summary

The most effective way of ensuring your infection control standards are acceptable, is to establish thorough practice hygiene procedures and detailed instrument reprocessing systems. Outline them clearly in a well set out, easy to read and accessible manual and regularly record that those processes have been carried out. By maintaining excellent documentation that supports your  infection control practices, it is easy to illustrate a clear understanding of the principles of infection control and that their importance is well understood by the practitioner and practice staff. Continued application and reviewing of infection control standards will help to ensure that your staff and patients will enjoy attending a well-organised, clean, hygienic and safe practice.

There can be no guarantee that any treatment will be entirely safe. All medical and dental treatment poses a "risk" to some degree and although often a negligible risk, the health outcome from any invasive treatment should always outweigh and justify the taking of that risk. For example, a patient with a diseased heart valve may be at risk of acquiring subacute bacterial endocarditis following a dental procedure. This risk is easily ascertained and recognisable. Consequently that risk is minimised by giving appropriate antibiotic prophylaxis before dental treatment.

Prevention of nosocomial infections, those contracted through provision of treatment, is a much more difficult concept. The agents causing these transmissible infections are many, from blood borne viruses through to bacteria such as methicillin-resistant staphylococci. Using all our knowledge of microbiology it is possible to reduce the risk of transmission of disease in a healthcare setting to the minimum. The simplest way to prevent transmissible disease is to ensure there is a "disease barrier" between the operator and the patient (direct transmission) and also between patient and patient (cross-infection or crosscontamination). To establish this "disease barrier" the implementation of a range of procedures is required. Examples of these procedures are sterilisation of instruments, maintenance of a hygienic and tidy operating field and use of barriers such as gloves and masks. The combined total of these procedures is referred to as Standard Precautions for Infection Control.

The adoption of Standard Precautions is undertaken to manage unknown risks and varying perceived risks, depending on your role in dental treatment. For example, the patient will have one perception of the risk of "catching something" from dental treatment, the dentist may have a totally different perception of that risk and the dental team yet another perception of that same risk. That indeed some risk exists is substantiated by previous documented disease transmissions in the dental setting, the most notable being that of HIV in Florida in the 1980's. Conversely, since worldwide adoption of Standard Precautions following that and other documented cases no further  transmissions of HIV have been reported. Some would argue that this proved the risk was very small and had been blown out of proportion, whereas others would argue that the lack of subsequent transmissions proves infection control works. Certainly the public perception is that infection control is a necessity and that it reduces the risk of contracting a disease from dental treatment. Patients do not expect to emerge from dental treatment with HIV or hepatitis and they are now educated by a multitude of media to expect exemplary standards of infection control.

In a country where there is an epidemic of blood borne viruses (BBV's) the chance of transmission from medical and dental treatment is increased. In a country where the prevalence of BBV's is low the risk of transmission will be low yet patients may still perceive the risk to be significant. Their expectations for safe delivery of treatment will be high and they will readily complain about perceived breaches of infection control where they believe their expectations have not been met or that their health has in some way been threatened. Patients, and society generally, demands that we deliver health care in a safe environment - that we wear gloves, masks, sterilise our equipment properly and operate in a hygienic setting. Therefore, infection control should play a significant part of your overall risk management strategies.

There is an expense involved in implementing appropriate infection control standards in dental practice, which is insignificant compared to the costs for both the community and the practitioner should a patient contract a BBV in the dental surgery. Likewise, lack of protocols to protect staff from transmissible disease produce a far greater burden should infection result due to lack of care.

There are many advantages in having excellent standards of infection control in your practice. Implementation of infection control requires a team effort and usually helps to create a happy, efficient working environment. The improvement in staff morale and efficiency resulting from well set out infection control procedures has been seen to improve practice economy. While in the past costs of infection control were thought to be excessive and unwarranted, the reality is that improvement in instrument maintenance and handpiece care, and placing greater attention to servicing of items such as air conditioners, water lines and suction traps have all extended the service time of these items.

There are national guidelines/standards outlining how to establish adequate infection control. It is generally considered that in a court of law these guidelines would be the reference against which an individual practice would be judged as providing acceptable infection control standards or not. Most dental boards will assess the validity of patient/staff complaints by the practices ability to provide evidence of implementation of these standards. At the very least practices should have AS 4815:2001 (although it is anticipated that the 2005 version will be released in July) and the CDNA ICG. They should also have a good practice manual and must document procedures carried out.

Some states, like South Australia, have non-profit organisations (AMADA) supported by the ADA which can accredit practices, offer infection control advice and help to educate staff. Most dentists crystallise their understanding of infection control after graduation, as it becomes highly relevant and more 'tangible' in the practice setting. Continuing education in infection control is essential. Dentists should continue to understand and meet patients expectations of infection control in the dental practice and should be aware of new technologies which may make infection control processes more efficient.