Cuspid Volume 2: Clinically Useful Safety Procedures in Dentistry

By John Laszlo

CUSPID - Clinically Useful Safety Procedures in Dentistry: Volume 1 and Volume 2.

This clinically oriented and illustrated textbook of over 1,600 pages published on the 1st August 2018 to coincide with the General Dental Council's introduction of Enhanced CPD for all dental registrants; now provides every member of the dental team with the means to easily undertake and complete ECPD in line with the GDC's requirements for outcome C: Developing and maintaining knowledge and skills in dental practise.

In the two volumes of CUSPID: Five safety critical subject areas are systematically presented:

CUSPID Volume 1:

Chapter 1: Medical Emergencies.
Chapter 2: Medicine and Drug Safety.

CUSPID Volume 2:

Chapter 3: Infection Control.
Chapter 4: Radiation Safety.
Chapter 5: Oral Cancer.

All GDC registrants from the vocational trainee, to the experienced practice principal leading a clinical team can use the 2 volumes of CUSPID to complete their ECPD. Furthermore, the essential roles of all dental care professionals are comprehensively recognized in this textbook. Dental colleagues who are certainly well-experienced but at times under-appreciated and often over-worked; nurses, technicians, therapists and hygienists can use CUSPID to achieve their ECPD goals.

By answering the 650 multiple choice questions and participating in Peer Review, some 80 hours of ECPD can be claimed and verified by completing the certificates and log sheets at the end of each of the 5 chapters. For dentists, this forms the core of the ECPD required by the GDC: 80 hours out of the 100 hours required in the 5 year ECPD cycle. For other dental registrants, by using CUSPID; the ECPD achieved can significantly exceed the 75 hours required for clinical technicians, hygienists and therapists, or the 50 hours required for technicians and nurses to complete their respective 5 year ECPD cycles, securing their registration with the GDC.

Carrying out the reflective reviews at the end of each chapter forms the foundation upon which a Professional Development Portfolio can be based, adding further to the ECPD totals which can be gained from CUSPID.

In addition to ECPD, learning from CUSPID provides an opportunity to achieve a solid working knowledge of the safety critical disciplines required for safe clinical practise.

Using both volumes of CUSPID ensures you are not only working safely, you are doing so in accordance with the most recent evidence based clinical guidelines; in line with the GDC's requirements for ECPD for every dental professional from August 1st 2018 onwards.

• Language: English
• Publisher: Xlibris UK
• Release date: Aug 1, 2018
• ISBN: 9781524597313

John Laszlo

John Laszlo BSc Hons BDS MFDS RCS(Ed) MJDF RCS (Eng) Member of the Faculty of Dental Surgery and the Faculty of General Dental Practice. The Royal College Surgeons England.

Book preview

Copyright © 2018 by John Laszlo.

Library of Congress Control Number:   2017913033

ISBN:                  Hardcover                       978-1-5245-9729-0

                            Softcover                         978-1-5245-9730-6

                            eBook                              978-1-5245-9731-3

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Any people depicted in stock imagery provided by Thinkstock are models, and such images are being used for illustrative purposes only.

Certain stock imagery © Thinkstock.

Rev. date: 08/22/2018

Xlibris

800-056-3182

www.Xlibrispublishing.co.uk

714121

INTRODUCTION TO VOLUME 2

Using this book will help you to complete your requirements for Enhanced CPD.

In volume 1, Medical Emergencies, then Medicine and Drug Safety were considered. All dental team members must be capable of dealing with medical emergencies and are required to demonstrate evidence of their competence to do so. Notwithstanding that, what is peculiarly noticeable by its absence is the lack of any requirement for dental registrants to undertake Enhanced CPD demonstrating proficiency with respect to drug safety and this contradiction remains despite the greatest levels of morbidity and mortality occurring in dentistry following the accidental or unforeseen actions and interactions of prescribed medicines.

Putting that anomaly to one side for a moment, in this second volume, Infection Control and Radiation Safety are presented in chapters three and four, after which oral cancer with a consideration of end of life care in the fifth chapter complete the second volume of this textbook.

While the duty for implementing infection control measures and upholding radiation safety often falls to a dental nurse who may be relatively inexperienced, the responsibility for the care of the patient with oral cancer can be found in the domain of the dentist with specialist qualifications.

Despite the diversity of these roles and undoubtedly the presence of a hierarchy in the dental team, where everyone is equal but all jobs are not; infection control, radiation safety and cancer care must remain at the heart of everyone’s Core CPD subjects.

In addressing the points made above, while all members of the dental team must be capable of dealing with the rare occurrence of a medical emergency, at the time of writing, in the advent of a new era of Enhanced CPD, no one is required to show proficiency in the everyday use of medicines and drugs that are regularly prescribed in dental and medical practice, the lack of understanding and maladministration of which can lead to medical emergencies!

If we consider that between these two extremes, arguably the most safety critical activity of all: Infection control, with the disinfection of the dental clinic and decontamination of surgical instruments is placed in the hands of dental nurses, many of whom are relatively inexperienced, then the critical essence of all dental professionals working as a cohesive team becomes clear.

Responding to such inconsistencies, the following words from Robin Olds written for a vanishing breed of men, serve not only as a reminder of the importance of team work that is efficient as it is effective, but for the need for you to constantly and critically look around you, not only in your operational environment; to the people you work with, but without fear of reprisal; for the need for you to look at those organisations staffed with their non accountable and non registered careerists and their directives that are irrational as they are inappropriate, which could ultimately compromise the safety of your patients:

image0001.jpg

"Here’s what I learned over the years. Know the mission, what is expected of you and your people. Get to know those people, their attitudes and expectations. Visit all the shops and sections. Ask questions. Don’t be shy. Learn what each does, how the parts fit into the whole. Find out what supplies and equipment are lacking, what the workers need. To whom does each shop chief report? Does that officer really know the people under him; is he aware of their needs, their training? Does that NCO supervise or just make out reports without checking facts? Remember, those reports eventually come to you. Don’t try to bullshit the troops, but make sure they know the buck stops with you, that you’ll shoulder the blame when things go wrong. Correct without revenge or anger.

Recognize accomplishment. Reward accordingly. Foster spirit through self-pride, not slogans and never at the expense of another unit. It won’t take long, but only your genuine interest and concern, plus follow-up on your promises, will earn you respect.

Out of that you gain loyalty and obedience. Your outfit will be a standout. But for God’s sake, don’t ever try to be popular! That weakens your position, makes you vulnerable. Don’t have favourites. That breeds resentment. Respect the talents of your people. Have the courage to delegate responsibility and give the authority to go with it.

Again, make clear to your troops you are the one who’ll take the heat".

Brigadier General Robin Olds AFC DFC.

July 14th 1922 to June 14th 2007.

These words are just as relevant today for dentistry and for any professional enchained in regulatory bureaucracy as they were fifty years ago for the pilots who were engaged in combat in the air war over South East Asia.

Returning to CPD, repeating what was stated in Volume 1:

image0002.jpg

Continuing Professional Development for dental professionals can be defined as: lectures, seminars, courses, individual study and other activities that can be included in your CPD record if they can be reasonably expected to advance your professional development either as a dentist or as a dental care professional and such activities are relevant to your practice or your intended practise of dentistry ¹.

CPD is a valuable source of support for dentists and dental care professionals to maintain and update their clinical skills, knowledge and professional behaviours ¹, ².

All registered dental professionals have a legal duty to maintain and develop their working knowledge and clinical skills so the dental treatment and oral care provided is safe and of the very best standard. To maintain registration with the GDC, specific CPD requirements must be met.

Participating in CPD is therefore a compulsory part of your registration with the GDC and the evidence that you are doing so needs to be retained. The CPD scheme has made an important contribution to patient safety and the previous requirements in place for nearly a decade have now been replaced with a new set of requirements entitled: Enhanced CPD. This is effective from the start of 2018 for dentists and from August 2018 for all other dental care professionals registered with the GDC. There are a minimum number of hours that must be completed during your five year CPD cycle and these can include contributions from:

336173.png

Almost anything can be included in your CPD record, however as underlined above and repeated again; such activity has to be reasonably expected to advance your professional development as a dentist or a dental care professional and it must be relevant to your practise of dentistry.

Examples of these can include:

336194.png

By working your way through this second volume of CUSPID, you can undertake all of those activities highlighted in the above boxes e.g: Individual study, or with your colleagues; you can participate in the other activities such as: Training sessions, Peer Review, or Clinical Audit and when combined with reading journals or other professional publications, this text book can provide you not only with a foundation for your 5 year Enhanced CPD program but a framework that you can use to support your plans for your personal and professional development which the GDC require you to undertake and demonstrate doing from 2018 onwards.

As a reminder: In your 5 year CPD cycle there will be a minimum number of CPD hours you must complete. These minimums are determined by your registration status; whether you are registered as a dentist or registered as a dental care professional. From January 2018 for dentists and from August 2018 for dental care professionals, the following changes to CPD came into effect:

The verifiable hours required over a five year CPD cycle will be:

Furthermore under these new requirements, you will need to keep a CPD record including:

The GDC have also stated that you may find it helpful to carry out CPD with other people, particularly other members of the dental team. This may be particularly helpful if you are a sole practitioner. In some circumstances, it will be useful for a dental team to carry out training together – for example, training to handle medical emergencies in the practice ¹. Therefore the five chapters in these two volumes can be used to undertake those activities outlined from the GDC’s recommended list of CPD sources and these can be:

336210.png

By participating in these activities using volume 1, the following two subject areas in your 5 Year cycle of Enhanced CPD can be completed:

336228.png

* As previously mentioned, despite the GDC not including Medicine and Drug Safety in your core CPD, given the safety critical nature of this subject, it is nevertheless recommended as an essential component of your Enhanced CPD.

In this second volume the following core topics in your 5 Year Enhanced CPD cycle can be completed:

If you are a dentist or a DCP completing your CPD under the transitional arrangements available until you fully participate in the Enhanced CPD scheme, by reading the chapters in this book and recording the dates and times in the logs provided, there is sufficient material for you to claim general CPD to both a quality and a quantity that is well in excess of the minimum requirements laid down by the GDC under both the previous and the present guidelines.

If you are in the transitional phase of your CPD, the GDC Enhanced CPD Transition Tool is available from: https://gdc.onlinesurveys.ac.uk/ecpdtool, using this together with this book should assist you in completing your transitional CPD requirements.

To claim Enhanced CPD you will need to read and revise the subjects within the chapters, then answer questions relevant to the subjects you have selected. Your CPD can be verified by recording the dates and durations for each activity in the CPD logs and then complete and sign the certificates provided at the end of each chapter. A counter signature from one of your GDC, GMC or NMC registered colleagues or your dental practice manager can attest to completion of this activity, confirming your participation in such CPD is verifiable and thus qualifies for inclusion in your Enhanced CPD portfolio.

For an activity to be carried out as Enhanced CPD, as a guide:

In total in the two volumes, there are 650 multiple choice questions; some questions have single answers and many questions have multiple answers, with a few questions having a range of answers. By taking: One hour for every 10 questions (you can choose the subject, the questions and the time taken to discuss the results), in total some 65 hours of Enhanced CPD can be recorded from this textbook just by studying for and then answering the multiple choice questions.

If this is completed across five years, this is neither an onerous nor an intensive exercise and by the end of your CPD cycle, a considerable amount of your Verifiable, Core and Enhanced CPD can be covered and completed in the company of your colleagues, either as a part of your dental practice team-training or as Peer Review Exercises. This activity can be easily accomplished during your working hours, comfortably exceeding the GDC minimum rate to participate in Enhanced CPD at:

Following from this approach to your CPD, if you are a dentist you will be left with 35 hours to allocate for those courses with mandatory attendance, such as: First Aid, Immediate Life Support and Paediatric Life Support. Even though your attendance on such courses is mandatory, by reading the material in this textbook, you will firstly be able to revise and secondly be able to reflect on your attendance on these courses.

By doing so, you can with a measure of confidence gain so much more from your attendance than if no background reading or study were undertaken beforehand.

If you are a clinical dental technician, an orthodontic therapist or a hygienist, you could complete 65 out of your 75 hours, while nurses and technicians could participate with their senior colleagues to complete or possibly even exceed your Enhanced CPD requirements from just reading this book and answering the multiple choice questions.

We shouldn’t overlook the opportunity to participate in Peer Review Exercises and that such activity can count towards Enhanced CPD! If you choose to select and to focus on subjects from within the 5 chapters, it would not be unreasonable of the GDC to expect that some 3 Hours +/- 1 Hour from each of the 5 chapters could be (or should be) set aside for Peer Review of those subjects. Therefore another 15 to 20 Hours of CPD could be reasonably claimed in a 5 Year CPD Cycle just by using the data in this book for Peer Review and for your Personal and Professional Development Portfolio thus:

In essence: For DCP registrants using this book, the Enhanced CPD requirements to maintain GDC registration can be met, while for dentists using this book and setting aside another 20 hours across a 5 Year CPD cycle for further verifiable CPD is no longer an inaccessible pinnacle to climb or another onerous burden to carry on your professional journey while ensuring your continued registration!

For some time, verifiable CPD has been defined by the GDC as requiring the documentary evidence that the dentist or the dental care professional has actually undertaken the CPD and further documentary evidence is required to prove that the CPD you undertake will have the following three items present:

If you are using this book as a basis for your Enhanced CPD, then the GDC state you must keep a record of this for up to 5 years after the end of your CPD cycle. In order to meet the GDC requirements your CPD record must include the documentary evidence attesting to the verifiable nature of the CPD, this can be achieved by completing and signing the log sheets, certificates and feedback forms found in the answer sections at the end of each chapter.

Please don’t forget to collect counter signatures from your registered colleagues who also participate in your CPD! Adding to this, the GDC have stipulated for CPD to be verifiable at least one of the following learning outcomes must be demonstrated in each activity you complete ².

Given the broad scope of these learning outcomes, if you study each of the five chapters and answer the questions at the end of each chapter, then you can demonstrate that you have maintained and developed the knowledge and skills within your field of practise. (Outcome IV above). With your participation, appraisal and reflection the other outcomes from the above list can also be achieved.

All verifiable CPD must be quality controlled.

While the GDC do not quality assure CPD activity, from April 2013, the GDC did expect that some form of quality assurance must be in place. The educational content of this textbook when used for verifiable CPD has been effectively quality controlled by the following means at the relevant stages ³, ⁵:

1. Quality controls in place before CPD:

2. Quality controls during the CPD activity:

3. Quality control after completion of the CPD:

CUSPID Volume 2: Clinically Useful

Safety Procedures in Dentistry.

Annual Record of Accumulated Verifiable CPD

Name: ……………………. GDC Number: …………… CPD Start date……………

As a reminder: CUSPID should count towards your Enhanced CPD activity given that:

Please retain and copy your recorded totals every year for the GDC

CUSPID Volume 2

Please copy as necessary and place in your portfolio or submit to the GDC.

CUSPID Log sheet for verifiable CPD

339085.png338422.png

References:

1.   General Dental Council. Continuing Professional Development for Dental Professionals.

Available online from:

file:///C:/Users/Owner/Downloads/Continuing%20Professional

%20Development%20for%20Dental%20Professionals.pdf

Accessed June 2017.

2.   General Dental Council. Enhanced CPD.

Available online from:

https://www.gdc-uk.org/professionals/cpd/enhanced-cpd

Accessed June 2017.

3.   General Dental Council. Quality Controls for Verifiable CPD.

Available online from:

file:///C:/Users/Owner/Downloads/Quality%20Controls%20for%20Verifiable%20CPD%20advice%20sheet%20(3).pdf

Accessed June 2017.

4.   European Commission for Education, Audiovisual and Culture Executive Agency (EACEA). Harmonisation & Standardisation of European Dental Schools. Programmes of Continuing Professional Development for Graduate Dentists – Dent CPD: Lifelong Learning Erasmus programme (#509961-LLP-1- 2010-1-UK-ERASMUS-EMHE).

Available online from:

http://www.dentcpd.org/workpackages/WP4/CPD_activity_

evaluation_toolkit_for_dental_educators.pdf

Accessed June 2017.

CHAPTER THREE

Infection Control

CONTENTS

Chapter 3: Infection Control

Introduction

The Educational Aims, Objectives and Outcomes in this chapter

The aim

The objective

The outcomes

Further expected outcomes in this chapter

Quality Control

References: Introduction to Infection Control and Safety in the Dental Practice

Infection control: Our problems

Those at risk from infection in the clinical environment

I.   The patients

II.   Non-clinical staff

III.   Technical personnel

IV.   Members of the public

V.   The clinical dental team

Infection Control: Our Patients

What does this all mean and what is the relevance to infection control?

Terms and definitions

I.   Immuno-competent

II.   Immuno-suppressed

III.   Immuno-compromised

IV.   Immuno-deficiency

V.   Immuno-incompetent

References to Infection Control: Our problems and our patients

Infection control: The Pathogens

1.   Bacteria

HA MRSA

CA MRSA

CA MRSA to HA MRSA and antibiotic prescribing in dentistry

ESKAPE

Clostridium species

Mycobacterium species

Pseudomonas species

Legionella species

2.   Viruses

Enteroviruses

HAV

HFMD

Herpangina

HBV

HCV

HDV, HEV and HGVs

The Herpes virus family

I.   Human Herpes Virus HSV 1 and HSV 2

II.   Human Herpes Virus HSV 2

III.   Human Herpes Virus 3: Varicella and Zoster

IV.   Human Herpes Virus 4, the Epstein Barr virus (EBV)

V.   Human Herpes Virus 5, the Cytomegalovirus (CMV)

VI.   Human Herpes Virus 6

VII.   Human Herpes Virus 7

VIII.   Human Herpes Virus 8

HIV, AIDS and society

The Human Immunodeficiency Virus and AIDS

HPV

Parvovirus

Rabies

Rubella

3.   Fungi

4.   Prions

References: The Pathogens

Infection Control: Protection and Procedures

I.   Inoculation

II.   Incubation

III.   Prodromal phase

IV.   Acute phase

V.   Chronic phase

The proportions of patients with HIV in the UK

The first steps towards protection

Vaccination and Immunisation

I.   Attenuated vaccines

II.   Inactivated vaccines

III.   Subunit vaccines

IV.   Toxoid vaccines

V.   Conjugated vaccines

VI.   DNA vaccines

VII.   Recombinant vector vaccines

Antibiotic Stewardship…the French Paradox

Hepatitis B and dentistry

I.   HB s Ag

II.   Anti HB c

III.   Anti HB s

IV.   HB e Antigen and HB e Antibody

V.   HBV DNA

Universal Infection Control Procedures

The subsequent steps

Cross Infection Control Measures

Hand hygiene

Hand contamination and length of appointment

Save Lives: Clean Your Hands!!

Three levels of hand hygiene

How to hand wash?

The universal use of gloves

Glove use and the Minimum Infective Dose

Glasses and/or visors

Footwear

Protective Clinical Wear

PPE: Three Legal Requirements

Another Three Legal Requirements

The Local Infection Control Policy

Washer-disinfectors

Manual instrument cleaning

Autoclaves

Reprocessing instruments

Clinical Zones

Establishing and maintaining your clean and contaminated zones

When things go wrong

Sharps Injuries: Preventive Measures

Risk reduction

Sharps Injuries: Treatment Procedures

References for Infection Control: Protection and Procedures

Chapter 3: Infection Control Verifiable CPD Questions

Answers Chapter Three: Infection Control

Certificate of Enhanced CPD in Infection Control

CUSPID Log sheet for Enhanced CPD in Infection Control

Evaluation and Self Satisfaction Survey

Professional and Personal Development in Infection Control

INTRODUCTION

This chapter will deal with Infection Control and the related safety issues that affect you and your patients in the dental clinic. The subject matter in infection control forms part of your mandatory Enhanced Continuing Professional Development (CPD). As one of the core subjects you have to keep up to date with, you also have to retain the documentary evidence to prove that you are doing so.

So that you are practicing infection control, decontamination and disinfection to the best of your abilities and to the highest standards that your patients deserve and your colleagues demand, your knowledge and skills in this subject must be:

I. Reviewed frequently, in staff meetings and through informal collegiate discussion.

II. Renewed appropriately, in accordance with the latest developments in this field.

III. Revised effectively, in line with the directions from your regulatory body.

In the UK, the General Dental Council (GDC) has stated, every Dentist and all Dental Care Professionals must undertake and complete 5 hours of mandatory verifiable training in decontamination and disinfection in every five-year cycle of Enhanced CPD.

There is a professional and a regulatory responsibility to protect your patients, your colleagues and yourself from the risk of infection transmission or indeed the acquisition of infections. In this chapter, the legal and professional frameworks governing infection control will be combined into one educational framework. You can then proceed with this framework to:

338617.png

By following this framework you will maintain and develop your awareness of infection control and your patients will have the best dental treatment in the safest possible clinical environment that you and all of your colleagues in the dental team can provide.

In this chapter, we will look at the infection control standards expected of you.

If you are practising outside the UK, you should make yourself aware of the specific requirements that your governing body or professional associations will demand from you, as these may be slightly different from the basis of this chapter that focuses on the Department of Health (DOH) standards and the GDC regulations in 2017/8.

Nonetheless, in Europe, the Commonwealth Countries and North America, infection control standards are now universally identical. However, as clinical knowledge evolves, changes based on evidence will be implemented and there may be some regional and administrative variations affecting the area you practice in.

In addition, we will look at the measures you need to take to protect your patients, the public, the dental team and yourself contained in the specific guidance issued in the HTM 01-05, published first in 2009 then updated in 2013.

By reading this chapter, together with the latest published guidelines and taking into account the administrative framework in your dental clinic, you will add further support to your already safe and effective work with your patients with regard to demonstrating your adherence to infection control.

Everyone who works in a clinical team (in the UK) should, by now, either be trained and qualified or undergoing an approved training course leading to qualification and then registration with the GDC. At appropriate intervals after qualification and registration in the CPD cycle, all dental team members must undergo refresher training that is verifiable to maintain a comprehensive and contemporary working knowledge of infection control.

In disinfection and decontamination, there are certain tasks eg: hand washing that need to be learned and then carried out repeatedly.

Such tasks are your responsibility and are only one essential part of a clinical skill-set in infection control measures that you must continually adhere to. Ultimately, your skills in disinfection and decontamination are for the protection of your dental patients, your colleagues and yourself.

By reading this chapter, together with the relevant and required regulations, you will build on the knowledge that you qualified with to maintain a safety-critical approach for infection control in your dental practice and in your practise of dentistry.

As a reminder, the GDC now recommend that in your Enhanced CPD cycle: 5 hours of verifiable continuing education need to be undertaken in Disinfection and Decontamination for every 5-year round of clinical practice you complete.

The GDC, the Surgical Royal Colleges, and the Post Graduate Dental Deaneries in the UK also recommend that training in this core subject will be undertaken on a regular basis and you do not, (ought not to) cram the 5 hours mandatory CPD into one frenzied sitting and print off a certificate to prove you can. It does not work like that in real life. In the four years, three hundred and sixty four days and nineteen hours, prior to your attempt to complete your required CPD, you may very well have been remiss in at least one or more of your duties to your patient and your dental team. Such an approach to core CPD may needlessly expose you or your patients to risks from unwitting breaches in infection control.

In this regard, ignorance cannot be offered as a defence either to the GDC in a regulatory or disciplinary process. Perhaps, recently at least, no other area of dentistry has attracted as much adverse media attention as alleged lapses in infection control, when even to date; no harm has been caused to the patients in the UK, at least. On the other hand, considerable reputational harm has been caused to the dental profession and dental professionals by the adverse media coverage dedicated to such breaches. The reported case of D’Mello in 2014 is just such a case in point:

Some 22,000 patients were thought to have been affected by breaches in infection control and 4,526 patients were then tested for HIV, Hepatitis B and Hepatitis C; as these viruses were stated to be: Present in the community. Only 5 new Hepatitis C cases were uncovered in what has been reported to be the largest look-back exercise in NHS history in the UK. ¹, ², ³.

In stark opposition to this incident in terms of numbers, outcomes and a history that shaped, but did not define how we operate today, is the story of Kim Bergalis. This case, from over a quarter of a century ago, was the first known occurrence of intentional transmission of HIV from a health care worker, the dentist; Dr David Acer, to his patient; Miss Kim Bergalis and another five patients. ⁴ In total, after testing from the US Centre for Disease Control (CDC) and the Florida Department of Health and Rehabilitative Services, 10 cases of HIV were linked to David Acer from a sample numbering 1,000 tests. ⁵, ⁶.

Whereas the former case is current and shows a media interested in promoting unfavourable publicity concerning an alleged lack of adherence to infection control measures, the latter case is historical. The case of Kim Bergalis illustrated that while infection control measures were ostensibly being adhered to, the transmission of HIV was intentional, with harm being deliberately caused to the patients and this harm occurred despite legislation in the USA, from OSHA (Occupational Safety and Health Administration) mandating infection control to a level, over a quarter of a century ago, we are only now beginning to comprehend and to implement in the UK.

Very soon after news of the Kim Bergalis case emerged from the USA, in the UK the GDC issued a blanket ban against any dentist or dental registrant who declared an HIV positive status from practicing clinical dentistry. Furthermore, the GDC then implemented mandatory HIV testing for dental students applying to register for the first time and HIV testing for those dentists returning to clinical practice. These infection control measures were in reality; unlawful and a regulatory over-reaction to an ill-perceived threat that could never materialise and in two decades: has not materialised:

In over twenty-five years since the Kim Bergalis case, the intentional transmission of HIV from a health care worker to a patient has not occurred again in the USA, the UK, in Europe or anywhere else for that matter.

Such unlawful measures and over-reactions from the GDC were driven into existence by the popular media of the time. While unhelpful and in many ways counter-productive, they did and still do serve to emphasize the importance of learning about infection control and an ongoing necessity to demonstrate a strict adherence to the standards expected from any dental professional while carrying out clinical work.

While for some of us the matter of infection, of microbiology and virology will always remain both an exciting and a thought provoking topic, we might not be able to find as many clinicians who would be similarly cerebrally stimulated by the rules and regulations supporting the very necessary need for infection control. In truth, the subject matter if tackled in the wrong way could very well be a mind-numbing experience. In truth, there is a lot to learn about the procedures we complete everyday and in reality, every day we do not give much thought to them, while actually carrying them out, to a very high level!

After revising the sections dealing with infection control procedures, we will also need to go over some of the rules and regulations that govern disinfection and decontamination. As noted above, it is appreciated that revising these cannot be appealing and certainly there are more appealing CPD subjects that you would rather concentrate on, but the fact remains that the latest facts supporting disinfection and infection control must be learned and then rigorously applied to your clinical procedures.

At this time, the dental practice you work in will be both CQC registered and HTM 01-05 compliant having an active training schedule to ensure both you and all members of your dental team undergo regular training in disinfection and decontamination. Within such a framework, you should be able to set aside at least an hour every few months to review and revise the information contained in this chapter and be well within your 5-year CPD cycle to complete your professional commitments to achieve your targets for enhanced CPD in this subject.

The Educational Aims, Objectives and Outcomes in this chapter

Review, renew and revise your active working knowledge of infection control in dentistry, keeping yourself up to date with the latest information in this field. There are clear aims and outcomes listed below. The CPD you complete in this chapter should comply with the GDC’s requirements for verifiable enhanced continuing professional development in the core subject of disinfection and decontamination.

The CPD that you undertake in this chapter should also focus on those subjects you have identified as learning requirements from your Professional Development Plan (PDP) and these can be completed as part of your Professional Development Portfolio.

The aim

The educational aim in completing this chapter will allow you to build a foundation of professional knowledge that is clinically applicable, providing a base from which you can broaden your understanding and thus enhance your clinical skills in disinfection and decontamination.

The objective

The objective of this chapter is to provide you with the core of knowledge and the understanding you need to competently and safely work in a clinical environment while adhering to the standards set out in the latest HTM 01-05 policy document.

The theoretical knowledge gained from completing this chapter should be combined with practical work based experience and training. Through regular revision of the evidence based theory of disinfection and infection control, in combination with revision of the practical infection control procedures you undertake, together with all members of your dental team; the safety of your patients will be guaranteed, as you complete the Enhanced CPD for infection control.

In addition to the professional and educational benefits for yourself and your team members, in completing this chapter you should be able to both attain and then maintain an improved level of practise, providing your patients with an ongoing clinical service that is both assuredly safe and up to date.

The outcomes

The outcomes of this chapter are for you to revise and update where necessary, the following:

Further expected outcomes in this chapter

In addition to these outcomes you will need to confirm your participation in regular group training exercises with other members of your dental team to demonstrate your knowledge and practical skills as part of a clinical team are maintained to an appropriate level.

To contribute to your Continuing Professional Development, you should correctly answer the questions at the end of this chapter to demonstrate that you have read and understood the principles of infection control and the relevant safety measures that are applicable to your dental surgery.

Quality Control

If the questions that you answer are marked by a third party, together with your regular training in disinfection and decontamination being logged and the results from your performance in these exercises being audited and combined with documented training by an appropriately qualified trainer, then working through this chapter will validate your Enhanced CPD.

Finally, the information in this chapter should be discussed in your regular dental practice meetings. By doing so and with your personal background reading, this chapter should count towards your personal development plan in this core safety-critical area.

References: Introduction to Infection Control and Safety in the Dental Practice

1.   NHS England News. Nottinghamshire dental patients recalled following apparent breach of infection control procedures. NHS England.

Online available from:

https://www.england.nhs.uk/2014/11/12/dental-recall/

Accessed March 2015.

2.   The Telegraph. HIV and Hepatitis scare. Dentist named. TMG Press Holdings.

Online available from:

http://www.telegraph.co.uk/news/health/news/11225474/HIV-and-hepatitis-scare-dentist-named-as-Desmond-DMello.html

Accessed March 2015.

3.   NHS England Press Release. Daybrook Dental Practice – Community Clinic blood test results confirmed. NHS England.

Online Available from:

http://www.england.nhs.uk/wp-content/uploads/2015/03/statmnt-confrmtn-bld-test-reslts.pdf

Accessed March 2015.

4.   Breo DL. Meet Kimberly Bergalis- the patient in the dental AIDS case. JAMA 1990. Oct 17; 264 (15): 2018-2019.

5.   Ou CY, Ciesielski CA, Myers G, Bandea CI, Luo CC, Korber BT, Mullins JI, Schochetman G, Berkelman RL, Economou AN et al. Molecular epidemiology of HIV transmission in a dental practice. Science. 1992. 256 (5060): 1165–1171

6.   CDC Possible Transmission of Human Immunodeficiency Virus to a Patient during an Invasive Dental Procedure. 1990 July 27. 39 (29): 489-493.

Available online from:

http://www.cdc.gov/mmwr/preview/mmwrhtml/00001679.htm

Accessed March 2015.

Infection control: Our problems

If we consider the two clinical cases in the introduction of: Desmond D’Mello and Kim Bergalis, then today in your dental clinic, the risk of any patient acquiring any infection must be zero, but we can never assume that it is zero and by not making such an assumption that it is zero, our clinical vigilance will be maintained. The risk of infection will always be present and for the dental patient this risk might come from contact with contaminated instruments or from dental equipment that has not been disinfected between patients. A member of the dental team who has not taken the necessary measures to protect themselves from cross infection could also present an infection risk to their patient.

Whereas the risk to the patient must be zero, there can never be no-risk for the dental professional. If we were to have a no-risk clinical environment for the dental team members, then all of the patients we treat would either be free from blood borne infections, or we would screen our patients specifically for such infections, selectively treating only those who were demonstrably free from blood borne infections. While the former is simply unrealistic, the latter approach is unethical, discriminatory and thus (quite rightly) unlawful.

Every day we work in dentistry, we must ensure our patients are treated with a no-risk approach to cross infection control.

A no-risk status must be achieved and maintained for our patients. However, for ourselves in clinical practice, we have to be pragmatic, accepting the risks inherent in what we do. While we cannot eliminate these risks, we must certainly do everything we can to minimize them.

If this approach can be coupled to a safety-critical and safety-conscious attitude, the risks we face from accidental exposure to infected and infective material, eg; from sharps injuries can be reduced to being almost zero and in effect; an acceptable and manageable level of risk can be achieved.

Those at risk from infection in the clinical environment

The following five groups are at-risk of acquiring infections from the dental practice environment if the disinfection procedures and cross infection control standards are sub optimal:

I.   The patients especially those patients who are at the extremes of age, either the very young or the very old. Additionally, those at the extremes of health are at an even greater risk. We will return to consider this group in greater detail in the following section.

II.   Non-clinical staff such as your administrative or reception staff who may not be registrants and have no clinical duties, yet they do come into close contact with the patients. These dental team members are the first and the last contact patients have in the dental clinic. On a daily basis, they will deal with patients in pain, patients on their way into the clinic and with patients who are still oozing blood and dribbling saliva mixed with blood on their way out of the clinic. While these dental team members may not be clinically trained, registered or ultimately accountable for their actions, they do face a considerable infection risk while they are at work.

III.   Technical personnel, who are responsible for servicing drains, suction pumps and all forms of complex and contaminated machinery in the dental practice, are in many ways; even more at risk from acquiring an infection than we might truly appreciate. They are prone to hand or finger injuries as they clean drains and sinks into which used anaesthetic needles and dental drill-bits have been intentionally and negligently discarded or lost through a moment’s accidental inattention.

IV.   Members of the public entering the dental clinic all those who accompany or chaperone the nervous patient to their sedation appointments, to the laboratory delivery driver, who comes to pick up the disinfected, secured and double-bagged impressions, that have only a few moments before been taken from one of your patients.

V.   The clinical dental team, everyone from your nurse to your practice manageress who may enter into the clinical environment to give assistance to yourself or support to a patient and do so on a routine basis or the thankfully extremely rare occasion in response to a medical emergency.

In essence, everyone working in or within a dental practice will be at some risk from acquiring an infection but for the patient, our non-clinical colleagues and any other visitor to the practice, this risk must be zero, while for ourselves we must aim to have no-risk, while accepting in reality the inherent hazards of our clinical work may leave us at best with not so much a no-risk profile but rather a low-risk profile.

The reality in dentistry is that everyone is at risk of acquiring an infection, with the risk increasing in proportion to the intensity of one’s clinical activities and the duration or frequency of exposure to those activities.

In your dental team, the receptionist and staff members who have administrative and non-clinical activities should in principle be at less risk than those dental team members directly engaged in clinical activities. However, should members of your clinical team be newly qualified or relatively inexperienced such as: vocational trainees, or trainee dental nurses, while their risk of infection may still be at a very low level, their risk of suffering a needle stick injury that could potentially lead to the acquisition of a blood borne infection with career-ending or life-limiting consequences may be higher than for your more experienced colleagues, simply due to their having not yet acquired adequate clinical skills or being aware of the risks that are present ¹.

On the other hand, such risks may decrease with the accumulation of clinical experience and a refining of surgical skills acquired over many years of clinical practise. However in the early years of clinical work, while the increased risks from treatment failures, complaints and litigation are well known, those from needle stick injuries have been less well documented, despite this paucity of evidence in the literature, please remember:

By the time members of your dental team will have achieved their qualification and applied for registration to work with you in practice, a period of approved training will have been completed and sufficient clinical experience will have been gained thus ensuring the necessary procedures and protective measures were learned (quite literally) to a degree that ensures those risks inherent in clinical dentistry will have been minimized to an acceptable level. Nevertheless with years of practice once more, through a process of risk-normalization the chances of an inoculation injury will begin to rise again.

Risk normalization is the process whereby we can become accustomed to seeing and then tolerating situations, processes and environments that are unnecessarily hazardous or dangerous; the idiom cutting corners succinctly explains this problem.

One way to control this problem is by practicing dentistry that is minimally invasive and so the risks can be reined in once more. Even if this approach is adopted there is clinical evidence to suggest that in addition to risk normalization there is a culture of either: under-reporting or actively: not-reporting incidents that are likely to breach cross infection control measures:

All health care workers surely know that injury with a contaminated sharp instrument such as a needle constitutes a major occupational hazard. One confidential survey in a UK hospital revealed that over one third (38%) of the respondents had experienced such an injury in the previous year, with nearly three quarters (74%) experiencing such an injury in their careers to date, yet barely over half (51%) actually reported such events! ²

Of considerable interest, from this study it was stated that nurses were more likely to report their injuries than doctors despite their having a lower risk profile in this regard. The results of this UK study are strongly suggestive of a culture of silence with respect to such injuries (in the NHS) ². One reason for such a response to this problem could be from the perceived consequential risks to health with the financial implications that follow which would seem to subordinate the ethical responsibilities to report such injuries.

In considering these results there are two things we must bear in mind:

I. This study addressed an issue that affects all health care workers, but only utilised data from medical staff, therefore the relevance of this data to the dental environment must be questioned, nevertheless:

II. If such a response described in the study as: A culture of silence.( ²) is evident among health care professionals, then what can we expect, other than the same from our patients in response to questions on their medical history that deal with broadly similar issues, such as their risk profile for HIV HBV and HCV?

With preventive measures and a conservative approach to dental practice, while the risk to the clinician will be minimized, it will still be the unprotected reception staff in your clinic whose risk of acquiring an infection will remain unchanged.

If such a risk is multiplied by the number of dentists working in your clinic, the potential for exposure to those pathogens being carried by the hundreds of patients who come into a close and an almost intimate contact with your receptionists as they pass through the dental clinic is quite considerable.

To this risk we can add another hazard presented to the administration and reception staff as they are frequently compelled to pick up tissues and swabs, most often contaminated, blood stained and simply discarded by patients in the reception and public areas of the dental clinic after their treatment is completed.

Despite all of these risks, reception staff, more often than not are seldom registered, accountable, protected or immunized from such hazards inherent in their work and when the true extent of what they are exposed to and the events they have to endure are critically considered, they could so often be truly under rated and under appreciated by other dental team members. In many respects and for many reasons their registration with the GDC is long overdue.

Infection Control: Our Patients

We must have control measures that truly result in no-risk of infection for our patients. That this should be so is borne in part from the expectations of our patients and our profession and in part from the demands of a public increasingly influenced by the internet and the popular press progressively probing our ever un-popular profession for something un-pleasant to write.

Putting such external pressures to one side, the real reason we need to observe infection control measures and do so scrupulously is:

For the safety of our patients, nothing more and certainly nothing less than this will suffice.

After several years of practise, you will certainly notice that patients come in all sizes, all shapes and all states of health. Whether you have worked in general practice, a specialist clinic or in a dental hospital, you will recognize that today more of our patients are taking more medications and many more are in extreme states of health ³. All of this means, overall, our patients are more susceptible to acquiring infections and receiving medication to treat those infections.

image001.jpg

It has been estimated that 1% of the UK adult population are taking oral glucocorticoids ⁴. These are used to suppress various inflammatory conditions, allergies and autoimmune disorders. In addition, they can be used to prevent the rejection of transplanted organs, but more commonly, you will have treated patients taking such steroids that are used to control the effects of chronic asthma and in those patients with adrenal insufficiency.

In addition to the 1% of patients taking glucocorticoids, there are: cytostatic agents, mono and polyclonal antibodies, drugs acting on immunophilins, the interferons and a strikingly novel array of prescribed medications to improve our patient’s quality of life as they continue to endure conditions from which a previous generation would have succumbed. We might also add that good old-fashioned opioids, (prescribed or otherwise taken) also reduce a patient’s innate and adaptive immunity ⁵.

What does this all mean and what is the relevance to infection control?

All of the above noted medications are commonly taken and while there are benefits, there will be side effects too. Invariably, immuno-suppressed patients will be predisposed to infections particularly viral, fungal, mycobacterial and protozoal infections as the patient’s T (Helper, Killer and Memory Lymphocyte) cell numbers and functions will be depressed. Patients who are immuno-suppressed will be susceptible to the effects of commensal micro-organisms resulting in opportunistic infections that might spread silently, rapidly and atypically ⁶.

image002.jpg

Some of the immune complications arising from medication.

With increasing numbers of dental patients being immuno-suppressed, the environment we treat them in must be a safe one, with no chance that transmission of any infective micro-organism from one patient to another via a contaminated instrument, work-surface or from airborne spread could occur.

Whereas infection of the perfectly healthy individual with a commensal organism might be a nuisance, something that frequently occurs outside the clinical environment, any infection that can be traced back to the dental clinic is far more problematic, being indicative of poor infection control standards.

If commensal species present as an occasional inconvenience for the healthy patient, then to the immuno-suppressed patient, such infections can be more than challenging. If we now move from the commensal species to consider the pathogenic species, then the issues become more serious.

As mentioned in the introduction, there have been cases of intentional and serial transmission of HIV from one dentist to his patients. In the years since that horror, there have been infrequent but noted accidental lapses of infection control measures in dental clinics resulting in unintentional transmission of Hepatitis C (HCV) and Hepatitis B (HBV) ⁷, ⁸, ⁹.

Although AIDS is still the headline grabbing big disease with the little name, we must not forget the risk presented by commonly occurring infections, for all of our patients, but especially for our older patients and not only those who are immuno-suppressed. We must be mindful of the effects that Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV) respectively responsible for Cold Sores and Chickenpox might have.

Recrudescence of these viruses can lead to a number of debilitating conditions. You will be aware of the risk to the patient’s eyes and your own eyes from the aerosol spread of HSV potentially causing ocular scarring and blindness. The risk of Herpetic Ophthalmitis if the Ophthalmic Division of the Trigeminal Nerve (CN V1) is involved and the painful presentation of shingles in other dermatomes with VZV in your older patients will be something you will have remembered well from your studies in both anatomy and microbiology.

Normal aging, poor nutrition, and immuno-suppression, all correlate with outbreaks of both HSV and VZV. Factors encountered by patients in the dental clinic such as physical and emotional stress or fatigue may also led to an episode of these infections recurring if the patient is already carrying these viruses albeit latently ¹⁰. Thus, an immuno-suppressed patient is at risk both from contracting these viruses and from passing them on and infecting others who may already be infected but who have no immunity to an altogether different subtype of HSV, VZV or any of the other commonly occurring viruses.

Sitting in a bus full of coughing schoolchildren on the way to work means you will catch the common cold and that is one of the hazards of being stuck in children, rather than traffic; if you use public transport. While no-one would consider taking action against the bus driver for transporting nasty little reservoirs of highly infectious pathogenic incubators around the countryside, the same indifference cannot be applied to a dental practice if patients start to complain that:

Every time I go to that dentist, I come out in a rash/ cold sores/ get a cold… ….

These are responses that many of our colleagues have received when asking: Why has a patient changed dentist, often after attending for many years? Thanks to the internet’s press publicity, patients are truly aware of the standards they deserve and have come to expect from dentists, with many being even more aware than we think they are, or ought to be. Overall, unless something serious happens with their dental treatment, very few patients will actively complain or approach that other repository of nastiness: the GDC.

Patients will in most cases actively seek out dental care elsewhere, seldom taking any further action.

Terms and definitions

Progressing from the patients who are immuno-suppressed we also need to consider those who are immuno-compromised, but before doing this, we would like to clarify both these terms and a few others, as they seem to be getting bandied around by everyone with little in the way of critical thought to their meanings. Below and on the next page are definitions of these terms as they apply to our patients and clinical dentistry. If any of you know immunologists out there who vehemently disagree, then please do let us know and we will welcome the corrections:

I.   Immuno-competent, a fully functioning immune system that is able to defend the body in a normal way following exposure from those antigens we cannot vaccinate and immunise against: The common cold, to those we can: Tuberculosis.

II.   Immuno-suppressed, an immune system functioning to a lower than ideal level due to the actions of medication or an inherent condition. The suppression can be lifted by removal of the medication causing the suppressive effect with a natural return to health, or by medication that can control a suppressing condition. An example might be the patient taking medication to reduce or remove the risk of transplant rejection. Or as noted above; patients who are taking steroid medication.

III.   Immuno-compromised, an immune system that is fundamentally damaged, due to the effect of an inherent condition, medication or an externally acquired agent or infection. With such cases, the immune system is irreversibly altered. Nevertheless, the patient is capable of mounting a defence that is either diminished or inappropriate. Examples are patients with HIV or patients enduring lymphomas or leukaemias, who are undergoing radiotherapy or chemotherapy.

IV.   Immuno-deficiency, an immune system that is missing an essential component and so the response to an antigen is either lost or inadequate. The patient is then susceptible to opportunistic pathogens that might not present as a clinical condition in an otherwise healthy patient. Examples are infection with HIV leading to AIDS, or the rare but catastrophic SCIDS (Severe Combined Immunodeficiency Syndrome)

V.   Immuno-incompetent, an immune system that simply does not work, either due to not being primed, in the case of a new born whose immune system is not fully functioning, but may already have some maternally protective antibodies, or patients who have HIV that has progressed on to AIDS in the absence of any effective controlling regimen.

While many of the above