Infection control lapse in a dental clinic
This story has been all over the news for the past week; I first saw of it via a Pennsylvania Department of Health alert, indicating that a local clinic had been found to be non-compliant for several very important infection prevention measures. I won’t recap the story here, as it is readily available elsewhere. Actions by the State Board of Health have been to suspend the doctor’s license while an investigation is in place, and to recommend to patients who had been treated there to seek out testing for potential bloodborne agents such as hepatitis B and C, and HIV. Recommendations from the State Board of Dentistry were to mandate that all employees of the practice have training in infection control, and to establish a set of documentation for the practice on best practices in the prevention of nosocomial infections.
Instead of dwelling on this particular case, which I think has been appropriately resolved by officials, I wanted to look at what the risks are in ambulatory practices in general, what infection control practices are mandated, and how this has changed. Back in the early days of dentistry–meaning in the mid 1980’s and before– routine cleanings and examinations were done (hopefully!) with cleaned instruments, however dentists and hygienists didn’t wear any personal protective equipment such as masks and gloves during procedures. The Centers for Disease Control and Prevention published this list of recommendations in 1986, with an updated set of recommendations in 1993. The assumptions for these practices were twofold; first, patients might be asymptomatic for a bloodborne agent, so a detailed patient history might not be informative to assess risk to office personnel and to other patients, and second, the main agents in questions (hepatitis virus, HIV) are readily shed through the mucous membranes contacted during oral exam. Recommendations at this point included mandating personal protective equipment for all clinic personnel, surfaces which might be difficult to disinfect like handles on equipment should be covered with disposable plastic wrap, and all procedures should be performed to minimize the risk of aerosolization of patient fluids. My personal recollection of these “best practices” put forward by the CDC is very much in line with what I experienced in dental clinics while in college in the 1980’s.
The CDC has good data describing the risks of patient to healthcare giver, particularly for hepatitis B and HIV transmission, and the rates with proper infection control practices in place are small. For patient to patient transmission, it is a bit more unclear but actual documented transmission of agents appears to be very low. In fact, the CDC reports only a single documented case of transmission from patient to patient of hepatitis B in a dental setting, and that occurred in 2001. The reason for this success likely goes back to the original recommendations linked above from 1986, which instead of striving for infection control, actually set forth a goal of infection prevention. The language is important; with “control” the aim is to reduce the number of incidents, and with “prevention” the goal is to eliminate the number of incidents. I think all Nursing students would do well to take this on as a goal in their own personal patient care, and work to prevent all nosocomial infections!