An update on the latest decontamination guidance for dental practices, by Edward Sinclair.
Infection control in practice
Infection control has come a long way since the early 1980s. Many practices, already introduced in hospitals, arrived relatively late to the dental profession. For example, the processing of instruments in a centralised facility had been routine in hospital for decades before reaching dentistry.
In England, HTM 01-05 was commissioned to bring in hospital-level standards of infection control and decontamination to primary dental care services. This, in turn, has changed practices in the devolved nations.
Much of the latest decontamination guidance is controversial amongst dental professionals as there is scant evidence for some of the protocols in HTM 01-05 and it was not formulated in a way consistent with the international standards on designing clinical guidance.
However, this may be in part due to a lack of research in general. Infection control is a large topic and can only be covered in brief in this article.
We will look at some of the most common infection control issues affecting surgeries across the UK and these are also among the most common questions asked of British Dental Association (BDA) advisors by dental professionals.
In Scotland and Northern Ireland, a separate decontamination room is mandatory, as is a washer disinfector. For England and Wales, these two items are required if a practice is to attain ‘best practice’ status, but it is not necessary to install retrospectively. However, individuals considering setting up a new establishment should be aware that the Care Quality Commission (CQC) expects new entrants to comply with this best practice.
Decontamination rooms do not have to be a set size and many practices will not have a choice in terms of which room they can use. Example layouts can be found in HTM 01-05 and Scottish Health Planning Note 13. It should be borne in mind that the room should be fit for purpose in terms of correct instrument flow and ventilation requirements.
For staff working in the room, it is important to consider their welfare in terms of the temperature in the room.
Whether it is used or not, manual cleaning must always be available as a backup, should decontamination equipment fail.
All equipment, whether mandatory or not, must be tested and maintained in order for it to be fit for purpose. For example, in England, all autoclaves, washer disinfectors and ultrasonic baths require validation annually. This must be performed by a competent person, usually a service engineer. Routine testing must be done according to the manufacturers' instructions.
For autoclaves, a daily check involves the automatic control test and the steam penetration test (vacuum autoclaves only).
All General Dental Council (GDC) registrants are required to undertake continuing professional development (CPD). Of the verifiable hours (75 for dentists and 50 for DCPs every five years),1 the GDC highly recommends certain key CPD topics. One of these is disinfection and decontamination, with five hours being the recommended amount in each five-year cycle. Thus, it is good practice to do at least an hour of infection control/decontamination training on an annual basis.
Infection control and the law
There are several different acts and regulations that concern infection control. The overarching piece of legislation is the Health and Safety at Work Act (HASAW) 1974.
From these, other regulations emanate, including Control of Substances Hazardous to Health (COSHH), which deals with biological agents, the Medical Devices Regulations 2002, the Safer Sharps Regulations 2013 and Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).
For England, the Health and Social Care Act 2008 gave birth to the CQC, as well as the Code of Practice on the prevention and control of infections and its related guidance.
This Code, whilst not a legal requirement to follow, makes reference to HTM 01-05 and is – in effect – the easiest way to ensure compliance with the infection control requirements of the Health and Social Care Act.
Staff immunisations and screening
Initially, it is important to group clinical staff into two distinct categories: those who perform exposure prone procedures (EPP) and those who do not.
As a rule of thumb, dental nurses do not perform EPPs, whereas hygienists and therapists do (a definition of EPP is ‘…where the worker's gloved hands may be in contact with sharp instruments, needle tips or sharp tissues inside a patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times'2).
New EPP workers are required to be screened for blood borne viruses before commencing clinical work. The word ‘new’ in this context refers to clinicians who are new to the UK healthcare system, be that NHS or private. This includes those who have just graduated from a UK university and those who have come to the UK from abroad without any previous history of working here. It does not include existing clinicians, so no retrospective testing is required. Non-EPP workers such as dental nurses are not required to have any testing performed.
All clinical staff require immunisation; the GDC expects registrants to take responsibility for their own health. Although there are no mandatory vaccinations, the BDA, based on accepted standards, recommends hepatitis B and tuberculosis (BCG) as a minimum, but, anecdotally, this latter vaccine appears to have some supply issues at the present time.
Salaried NHS employers may well have stricter, local requirements. Anyone in any doubt should consult their local occupational health department for further advice.
Employees of dental practices and those employed directly with the NHS can expect their employer to provide them with vaccinations free of charge, as well as ongoing occupational health cover and advice.
All trainee dental nurses should be offered hepatitis B vaccination and chairside assisting can begin after the first jab, so long as a risk assessment has been carried out. The onus is on the employer to take all reasonable steps to prevent an inoculation injury when the nurse is only partially immunised. Therefore, control measures need to be in place and these can include items such as no manual cleaning and no sharps handling.
Some individuals will not respond to vaccination; this does not prevent them working clinically, but it should be documented with the local occupational health office.
A new occupational health specification came out from NHS England in March 2016 and this allows DCPs to obtain cover via their employer; a useful website to find the nearest centre is www.nhshealthatwork.co.uk/find-providers.asp.
Gloves and hand hygiene
All routine dental procedures require gloves to be worn. These can be either latex or an alternative material, such as nitrile. It is not a requirement to have a separate latex allergy policy, as this would be included in the practice COSHH assessment. Avoid purchasing the cheapest gloves on the market, as these can cause allergies more readily due to their lower quality. It would be advisable to choose gloves that are CE marked and have low levels of extractable proteins (<50 μg/g of latex proteins). Gloves should be removed aseptically and hand washing should occur at regular intervals, especially between patients.
A useful hand hygiene policy is available on page 76 of HTM 01-05.3
Legionella risk assessment and dental unit water lines (DUWLs)
All practices must manage the Legionella risk. A risk assessment should be done by a competent person and the resulting list of instructions should help to keep this risk under control. That said, dental surgeries are a low risk environment for Legionella. The risk assessment remains valid until anything changes, for example, with the pipe work or plumbing. As a rule, the assessment should be reviewed every two years.
Dental unit water lines (DUWLs) are best managed according to the manufacturers' instructions, but commercial products can be very useful in the absence of any instructions.
The Safer Sharps Regulations 2013 have been devised to lower the number of needlestick injuries in clinical practice. For dentists, this has meant switching to a safer sharp system, where reasonably practicable to do so. A safer sharp is defined as a syringe system that consists of a retractable sheath to remove the need for recapping manually and there are at least two on the market.
It is well known that the old metal syringe system has been in operation for decades and many clinicians are content using them. However, given these new regulations and the numbers of practices using new systems, it is getting increasingly difficult to justify the use of the old system.
On the topic of inoculation injuries, these generally pose a low risk of actual harm, but all must be reported and followed up appropriately. This ideally should be at a local occupational health service set up in advance and should also be where records of immunisation are kept.
You might avoid using A&E unless the injury occurs out-of-hours and Public Health England has an emergency advice line on 020 8200 4400.
Single use items
Any item marked with the symbol above indicates that it cannot be reused under any circumstances and to do so would be to contravene medical device regulations. Many items that are classed as reusable are in practice difficult to clean – for example, small burs and other items can pose a challenge. Decontamination advice recommends that where reusable items are difficult to decontaminate successfully, consideration should be given to treating them as single use items.
Decontamination of impressions and dentures
Very little official guidance exists on these items, but given the variety of materials used, guidance dictates that manufacturers' instructions should be followed. In the absence of these, full immersion in a perform bath would be preferable to using a spray.
Above are some of the many topics that arise in everyday general dental practice. The BDA has more information on them in its infection control advice sheets [if your principal is a member] and there are numerous courses available.
This article has four CPD questions attached to it which will earn you one hour of verifiable CPD. To register on the free BDA CPD hub, go to https://cpd.bda.org/login/index.php.