AUTHOR: Louis G. DePaola, DDS
AUDIENCE: Dentists; Dental Hygienists; Dental Assistants; Specialists; Office Staff
ABSTRACT: Failure to comply with infection control standards increases the risk for disease transmission and jeopardizes patient safety. The course reviews the occurrence of healthcare associated infections (HAIs) and some of the common breaches in infection control that cause them. It touches on disease transmission prevention practices and the importance of vigilance of healthcare workers to keep themselves, and their patients, safe. The course then delves deeper into recent infection control breaches in dentistry and how not only the patients, but the dental practitioners themselves, were impacted.
- Be able to identify the factors that increase the risk of healthcare associated infections (HAIs).
- Understand modes of infection transmission and the length of time bacteria can live on inanimate surfaces.
- Learn about recent infection control breaches in the dental industry.
- Reiterate the importance of maintaining infection control standards and understand the consequences that may come from non-compliance.
CLINICAL CATEGORY: Infection Control
CE ACTIVITY: Self-Instructional
NUMBER OF CREDITS: 2 CEU’s
PUBLISH DATE: August 22, 2013
EXPIRATION DATE: August 22, 2016
COURSE CONTENT: The information and opinions contained in this CE course are those of the author, and do not necessarily reflect the views of The Richmond Institute for Continuing Dental Education, or its affiliates. Any brand or product name mentioned throughout this course should not be inferred as an endorsement of any kind by the aforementioned parties. In addition, The Richmond Institute does not warrant or make any representations concerning the accuracy or reliability of the materials on this website, or any site(s) that are linked to richmondinstitute.com.
CONFLICT OF INTEREST: Dr. DePaola has received research support from Colgate® and serves as a consultant for Biotrol™, Colgate®, Dentsply, Johnson and Johnson, and The Richmond Institute. The Richmond Institute for Continuing Dental Education is a division of Young Innovations, Inc.. It is dedicated to ensuring that its continuing dental education programs are intended for the sole purpose of education and do not serve as an endorsement for any product(s) or service(s), including those of the sponsoring company.
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SCORING: To earn credit for completing a course from The Richmond Institute for Continuing Dental Education, participants must earn an overall score of 80 percent or above on the associated exam before receiving a certificate that confirms CE accreditation. (*NOTE: There is no limit to the number of times a participant may re-take the exam in order to obtain this passing score). All courses that are published on this site are categorized as self-instructional—which means participants must complete the course on their own time and submit the accurate payment in order to earn CE credit.
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STATE DENTAL PRACTICE ACT: It is the responsibility of the participant to adhere to all laws and regulations proposed by the state that he or she is licensed to practice in. The Richmond Institute and its authors are not responsible for the participants’ use or misuse of the techniques and procedures discussed in this course.
LIMITED KNOWLEDGE RISK: The information provided in this course may not be comprehensive enough for implementation into professional dental practice. It is highly recommended that additional information be attained once the course is completed to establish greater proficiency on the topic at hand.
The Richmond Institute for Continuing Dental Education is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp.
Infection Control Is Not Optional: Dental Practitioners Need to Be Involved
The practice of dentistry is very demanding—patients must be scheduled, supplies ordered, staff issues dealt with, and numerous other details must be worked out each and every day. With such a high level of activity, there is a tendency to cut corners to fit everything in to the daily schedule; unfortunately, when this occurs, something is compromised. In the area of infection control, any lack of compliance with published guidelines can result in a significant risk for disease transmission and patient safety.1,2 A number of documented breaches of infection control in at least four states have been reported in 2012-2013. In each of these cases, patients have been advised to be tested for bloodborne infections (HIV, HBV, HCV) and the dentist has had his or her dental license suspended or revoked. This article will review the microbial threat facing the dental practitioner in 2013, some of the recent documented breaches of infection control in the dental office, and illustrate how such breaches of infection control can be prevented.
The Bugs Win:
What happens when we ignore the principles of microbiology and infection control? Diseases are transmitted, people get sick, and some may die; furthermore, careers can be ruined. The importance of infection control simply cannot be overstated. The microbial threats facing us today are significant, and the situation is not likely to improve. Highly resistant organisms are now commonplace and are the cause of healthcare associated infections (HAIs). The CDC estimates 1.7 million HAIs occur each year in the USA, contributing to the death of 99,000 patients annually. 3,4
HAIs have emerged to become the fourth leading cause of death in the USA and kill more people each year than AIDS, breast cancer, and auto accidents combined.3,4 Approximately 5 to 10% of hospitalized patients in the developed world acquire such infections5 – a great majority of which are preventable. Proper use of hand-hygiene is critical to the prevention of these infections;5 however, compliance among HCWs is usually below 40%.5,6
Contaminated medication(s) have been linked to disease transmission. The CDC and FDA have confirmed the presence of a fungus identified as Exserohilum rostratum in unopened medication vials of preservative-free, methylprednisolone acetate, which were injected into the joints and spines of patients suffering from injuries, arthritis, and other joint degeneration.7 This contamination resulted in a multi-state outbreak of infections—many of which were severe and very difficult to treat. As of July 2013, the CDC had already reported a total of 749 patients that had been infected with fungal meningitis, joint, and other infections in 20 states, with 63 reported deaths.7 Breaches in infection control in the drug manufacturing plant resulted in the contamination of the methylprednisolone; when the principles of microbiology and infection control are not followed, diseases are transmitted and people can—and do—die.
Almost everything in a healthcare setting can serve as a reservoir and a vector for opportunistic pathogenic organisms. This includes, but is not limited to: surfaces, hands of HCWs, and medical/dental equipment and/or devices.1,2,8 Factors that increase the acquisition of infections in any healthcare setting, inclusive of dental, include:
- The persistence of some bacteria and viruses on inanimate objects and surfaces for days, weeks, and months
- The lack of compliance with hand-hygiene recommendations
- Breaches in evidence-based infection prevention practices
- The tendency to cut corners by existing staff
- The growing volume of patients admitted in acute-care hospitals,
- The growing shortage of healthcare professionals
- Poor sanitation in healthcare facilities1,2,8
Surfaces play a significant role in the acquisition, persistence, and spread of infections. Clinically important microorganisms that can cause HAIs have been shown to persist in every healthcare environment for considerable periods of time;9 this facilitates the spread of the organism throughout a healthcare (dental) facility—especially when compliance with hand hygiene and surface cleaning/disinfection is poor. Contaminated hands have been shown to be the vector for the spread of viruses to multiple surfaces, devices, and patients throughout a healthcare facility. Unclean hands can also be the source of re-contaminating any surface that has been previously disinfected.9 Due to the overwhelming evidence of low compliance with hand-hygiene, the risk from contaminated surfaces is significant. Figure 1 clearly illustrates how a contaminated surface with low hand hygiene compliance can put a patient at risk for the transmission of pathogenic viruses, bacteria, fungi, and other microorganisms. 9
Viruses from the respiratory tract (corona virus coxsackie virus, influenza virus, SARS, and, rhinovirus) can persist on surfaces for several days. Bloodborne viruses, (HBV or HIV) can persist for more than one week. 9 Herpes viruses such as CMV or HSV Type 1 and 2, commonly encountered in the dental office, persist on surfaces anywhere from a few hours to as many as seven days;9 however, viruses from the gastrointestinal tract (astrovirus, HAV, polio- and rotavirus) can persist for approximately two months.9 Bacteria can persist for much longer periods of time; most gram-positive bacteria can survive for months on dry surfaces, and many gram-negative species can also survive anywhere from weeks to months. 9 Table 1 clearly illustrates this phenomenon.
Disease Transmission in the Dental Office:
Although the transmission of infectious diseases in all healthcare settings, including dental, has been well documented, many dental offices DO NOT follow recommended infection control standards. The CDC reports that patients are put at risk for disease transmission in the dental office because of:
- Cross contamination
- Unsafe injection practices
- Lack of personal protective equipment and hand-hygiene
- Incomplete or total lack of instrument cleaning
- Improper biological monitoring of sterilizers
- Inability to perform and/or verify sterilization1,2,8
Since 2012 patients have been put at significant risk of acquiring infectious diseases from dental practices in four states: Colorado, Oklahoma, Arkansas, and Pennsylvania. Although these cases are a matter of public record; the names of the dentist has been omitted in this publication. How did this happen?
Colorado 2012: Unsafe Injections at an Oral Surgeon’s Offices:
In July of 2012 the Colorado Department of Public Health and Environment announced the results of an investigation of an oral surgeon’s office.10 Serious breaches of recommended safe injection practices were documented.10 A release from the Colorado Department of Public Health and Environment advised patients of this oral surgeon that:
- “Between September 1999 and June 2011, syringes and needles were re-used for multiple patients to give intravenous (IV) medications, including sedation. The IV medications were given during oral and facial surgery procedures. Needles and syringes were used repeatedly, often for days at a time. Because there can be a small amount of blood that remains in syringes and needles after an injection through an IV line, there is a risk of spread of bloodborne viruses, such as HIV, hepatitis B, and hepatitis C, between patients. Due to the concern for the spread of HIV, hepatitis B, and hepatitis C, patients who received IV medications at this oral surgeon’s offices between September 1999 and June 2011 are advised to contact their health care provider to be tested for HIV, hepatitis B, and hepatitis C.” 10
This flagrant breach of safe injection practices and the principles of infection control have resulted in considerable angst for the patients who put their trust in this dentist, and have led to the revocation of this oral surgeon’s license to practice dentistry. Additionally, this has subjected him to protracted law suits that will undoubtedly go on for years.
HIV Test Urged for 7,000 Oklahoma Dental Patients:
On March 28, 2013 Oklahoma Health officials said that more than 7,000 patients of an Oklahoma City oral surgeon should undergo testing for HIV, HBV, and HCV. This action was taken after officials looking into the source of a patient’s HCV infection discovered the dentist’s instruments were not being cleaned and/or sterilized properly.11 The Oklahoma Board of Dentistry said inspectors went to the practice after a patient with no other known risk factors tested positive for both HCV and HIV infection11 During the inspection, investigators found multiple sterilization issues, including cross-contamination of instruments and the use of a separate, rusty set of instruments for patients who were known to carry infectious diseases. 11 Two sets of instruments were used: one for patients with known infectious disease (ID) and another for patients without known disease; each had a different cleaning method. 11 The ID instruments were dipped in bleach in addition to other cleaning solutions and were found to be pitted and rusted. 11 According to the CDC, pitted, rusted, porous instruments cannot be properly sterilized. 11 The autoclave in the office had not been biologically monitored in six years, making sterilization of any instruments used in the office highly questionable.11 The dentist of this office, which had no written infection control protocol, is suspected of using single vials of medications on multiple patients and allowing unlicensed individuals to perform procedures that would require licensure, such as administration of intravenous medications. 11
This case received nationwide press coverage and was an embarrassment to the entire profession. Multiple breaches in the principles of infection control have resulted in revocation of this oral surgeon’s license to practice dentistry and lengthy litigation. The patients have also experienced a high degree of concern. Of the 3,122 patients tested by April 16, 2013, 57 tested positive for HCV, three tested positive for HBV, and at least three positive for HIV.11 It may take years to determine which of those, if any, were infected by this oral surgeon. Compliance with standard precautions and recommended sterilization practices could have prevented all of this from occurring.
Arkansas Department of Health Recommending Blood Tests for Some 100 Patients:
On April 9, 2013 the Arkansas Department of Health (ADH) began contacting about 100 patients (ages ranging from 14-22 years) treated by a Little Rock dentist at six dental clinics around the state between November 20, 2011 and February 20, 2012. These patients were informed they may have been exposed to “infectious materials,” and were advised to get blood tests for HIV, HBV, and HCV.12 It is suspected that some of the drugs this dentist administered intravenously to patients may have been contaminated.12 The dentist had a history of substance abuse and, based on information received from the DEA, the ADH has concluded that some of the drugs used by him may have been contaminated with infectious material.12 The dentist has died, however, the cause of his death has not been released.12 At this time, the AHD states that only patients who received IV medicines (directly into a vein) from this dentist from November 20, 2011 to February 20, 2012, may be at risk.12 This case is a little unusual, in that it could represent a deliberate contamination of IV drugs due to the substance abuse of the dentist.
Dentist in Springettsbury, PA Put Patients at Risk for HBV, HCV & HIV
On April 29, 2013 Pennsylvania Department of Health, State Board of Dentistry temporarily suspended the license of a general dentist in Springettsbury, PA after an unannounced inspection on April 24, 2013 documented that this dentist did not properly sterilize some devices used in patient treatment. 13 Subsequent to the investigation, the state’s department of health is recommending HBV, HCV, and HIV testing for all current and former patients of this practice. 13 In a letter to the patients in this practice the Pennsylvania Department of Health announced that:
- “The Pennsylvania Department of Health (DOH) is advising all current and former patients of a York County dentist they might be at risk for infection after an investigation discovered the dental facility did not follow appropriate infection control procedures.
- To date, the investigation has found the dentist did not properly clean, disinfect or sterilize devices at her dental office.
- The departments of Health and State conducted a joint, unannounced site visit of this dental practice on April 24. The Pennsylvania State Board of Dentistry temporarily suspended the dentist’s dental license on April 29.
- Currently, DOH has not received any related reports of diseases or illnesses being spread to or among patients of this dentist. Out of an abundance of caution – and to ensure the wellbeing of the public – DOH is recommending current or former patients of this dentist get tested for hepatitis B, hepatitis C and human immunodeficiency virus (HIV).
- Additional information regarding this investigation can be found on the DOH website.” 13
This dentist’s license has been suspended, patients have been subjected to a great deal of anxiety and the reputation of this dentist has been severely compromised. Proper cleaning, disinfection and sterilization of devices used during patient care could have prevented this action by the State of Pennsylvania.
Infection Control Is Not Optional
The four recent cases presented in this article clearly document that compliance with the principles of infection control were not followed. While these cases represent a very small minority of practitioners, the fact that breaches as significant as these are occurring is disturbing. While each of these dentists is suffering their own personal consequences, the patients who entrusted their care to these oral health professionals are truly the victims. Dental practitioners have the moral, legal, and ethical responsibility to deliver oral health care in as safe a manner as possible; do not let your name or your practice be associated with one of these breaches of infection control. All dental practitioners must strictly adhere to the principles of infection control published by the CDC. 1,2 As clearly illustrated in this article, failure to be compliant with infection control can have catastrophic negative consequences to both the patients being treated in that office and the dentist/dental staff in the practice. The chain of infection (Figure 2) cannot be left unbroken or disease transmission may occur. Standard precaution and safe injection practice must be adhered to every day for every patient. Proper cleaning and sterilization must be performed and all equipment/devices must be monitored to insure that it is functioning properly and proper disinfection/sterilization has occurred. It often takes years to establish a successful dental practice, but once the trust between patients and a dental practice has been broken, it may take years to reestablish that practice—if it can be reestablished at all.
Infection Control is not optional: dental practitioners need to be involved and actively monitor that everyone on the dental team is compliant with all of the principles of infection control.
- Centers for Disease Control and Prevention (CDC). Guidelines for Infection Control in Dental Health-Care Settings Guidelines for Infection Control in Dental Health-Care Settings, December 19, 2003 / 52(RR17);1-61. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Accessed August, 2013.
- Centers for Disease Control and Prevention (CDC). Guide to Infection Prevention For Outpatient Settings: Minimum Expectations for Safe Care, May 11, 2011. http://www.cdc.gov/HAI/pdfs/guidelines/standatds-of-ambulatory-care-7-2011.pdf, Accessed August, 2013.
- Klevens RM, Edwards JR, Horan TC, Gaynes RP, Pollack DA, Cardo DM. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Reports 2007;122:160-166.
- Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, 2009. http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf. Accessed August, 2013.
- WHO guidelines on hand hygiene in health care. Geneva: World Health Organization, 2009. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. Accessed Augus,t 2013.
- Longtin Y, et al. Hand Hygiene N Engl J Med 2011; 364:e24 http://vigigerme.wordpress.com/2011/04/06/new-england-journal-of-medicine-features-hand-hygiene-video/. Accessed August, 2013.
- Centers for Disease Control and Prevention (CDC). CDC Responds to Multistate Outbreak of Fungal Meningitis and Other Infections. http://www.cdc.gov/HAI/outbreaks/currentsituation/. Accessed August, 2013.
- Collins AS. Preventing Health Care–Associated Infections. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 41. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2683/. Accessed August, 2013.
- Kramer et al. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review BMC Infectious Diseases. 2006 6:130. http://www.biomedcentral.com/1471-2334/6/130. Accessed August, 2013.
- Colorado Department of Public Health and Environment. Unsafe Injections at an Oral Surgeon’s Offices, Frequently Asked Questions, Updated July 20, 2012, http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheadername1=Content-Disposition&blobheadername2=Content-Type&blobheadervalue1=inline%3B+filename%3D%22Frequently+Asked+Questions.pdf%22&blobheadervalue2=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251816616499&ssbinary=true. Accessed August, 2013.
- Oklahoma Board of Dentistry. Statement of Complaint Against Wayne Scott Harrington, DMD, Case #: 13-005, March 28, 2013. http://www.ok.gov/dentistry/documents/harrington%20official%20complaint.pdf. Accessed August, 2013.
- Associated Press. Jeannie Nuss, Officials urge Arkansas dentist’s patients to get tested, April 10, 2013.http://www.cnn.com/2013/04/10/us/arkansas-dentist-investigation
- Pennsylvania Department of Health. Department of Health Investigating Yoirk County Dentist, June 4, 2013. http://www.portal.state.pa.us/portal/server.pt?open=514&objID=1525641&mode=2. Accessed August, 2013.