Making the Grade: Do Dental Practices Need Hospital-level Infection Control?

At first blush, one might assume that hospitals must adhere to higher infection control safety standards than dental practices. After all, hospitals handle complex medical cases such as surgeries, childbirth, and emergency care. Patients and clinicians at a hospital need protection from all sorts of risks.

But, thinking that dental practices don’t need to adhere to a similar level of infection prevention is simply not true. The reality is that both need to observe meticulous levels of care.

Compare and contrast

“Having been in dentistry for a long, long time, I understand some of the misconceptions or confusion – or perhaps old ideas that don’t go away in a lot of industries,” Peggy Spitzer, dental hygienist and clinical education manager for Certol International observes. “In dentistry, we’ve oftentimes felt, ‘Well, we can’t kill anybody and it’s just dentistry,’ ‘It’s non-invasive,’ ‘There’s a lower risk,’ I guess that’s probably what it comes down to – people feel like it’s a lower risk. They don’t understand that there are some significant changes, and no matter what, it’s patient care and it’s about the health and safety of the patient.”

Team members in both environments must observe much of the same standards of infection control.

“If we’re looking at environmental cleaning in the dental setting and the hospital setting, those should be very similar,” Joyce Moore, RDH, an infection control consultant and clinical instructor at Bristol Community College in Fall River, Massachusetts says. “The cleaning and disinfecting procedures and the chemicals that we’re using should very much align.

“There are some differences with hospitals,” she says. “Unlike dental, there is a higher focus on dust mitigation, and that’s not going to apply so much to the dental setting. Dust can contain a lot of contaminants. If you are in a surgical setting, you would not want dust getting into an open wound site.”

While hospitals see patients with varied medical needs, it’s important to remember that dental clinics serve patients with their own unique health concerns, underscoring just how important it is to maintain proper infection control.

“Dentistry is much more invasive than people may realize,” Spitzer observes. “And it’s getting more invasive. General dentists are doing more and more surgery. They’re placing implants. They’re doing some aggressive, very invasive procedures.

“And the other corollary to this is that people are coming into the dental office that never came in before,” she continues. “There are people in the middle of cancer treatment. There are people undergoing all sorts of extensive procedures or have a heavy-duty medical history. In the past, they simply were not healthy enough or didn’t survive long enough to have dental care. And now you have this combination of more invasive procedures on people who may be more at risk and they’re more immunocompromised. Those 2 factors alone would be a great concern, but the germs don’t care. The germs are out there and they’re opportunistic. They’ll take any advantage. And if we give them 1 small opening, they’ll go for it.”

Another difference is that hospitals have more equipment to sanitize – both medical and incidental.

“In dental, we are fortunate in that we simply don’t have as much equipment as they do in the other settings, because they’re looking at patient monitors and ultrasound equipment and infusion pumps, and they’re also looking at things like TV remote controls and call lights,” Moore says. “So, in the dental setting, yes, we are a medical profession, and we should have cleaning and disinfection and invite environmental cleaning standards that are very similar to the hospital. But there will be things that we don’t have to contend with, like those items.”

Signs of the times

As with anything in the last couple of years, COVID-19 has demanded a new level of safety.

“Dental settings – and just everybody in medical, because of COVID – have had a spotlight shone on what we were doing,” Moore observes. “And it’s had people reassess their policies, their procedures, and the way they practice. In dental, where we get away from medical, is that we don’t have separate, dedicated staff to perform these tasks. So, when it comes to the dental hygienists, the dental assistants, the dental practitioners performing those environmental cleaning procedures, we are doing pretty well, but we really need to be looking at the chemicals that we’re using and how we use them. So, across the board, I think it’s important to have your dental staff looking at how to properly use these items, especially because with COVID, we weren’t always able to get our usual products.”

There is also the reality of dental practices’ sizes, when compared to hospitals, and practitioners’ attitudes that may affect the levels of environmental sanitation.

“There’s just a lot more out there circulating now,” Spitzer says. “I’m afraid that that’s been very pervasive and it’s changing, because, unfortunately, I think there’s still the financial pressure that weighs heavily in dental. In many instances, it’s a single-practitioner, cottage industry type of setting, where you’re not in a group setting. You’re responsible to yourself. You should be responsible to the patient, but there’s very little oversight on a day-to-day basis, even in group practices. The dentist is in the room with the patient, the dental assistants, and the instrument processing area by themselves.

“There’s just not much oversight or group attention, and there’s not a lot of regulatory oversight and there’s not a lot of inspections,” she continues. “All those factors are playing into this situation, so that people will say, ‘Well, we don’t have to do that,’ ‘We don’t have to do these extra steps or extra monitoring devices when we’re doing sterilization,’ ‘We don’t have to worry about doing all these steps of instrument cleaning,’ ‘If it’s excessive, it’s too much, we don’t have to package our handpieces. We can just sterilize them and throw them in the drawer,’ There’s a lot of these sorts of things that I think are alarmingly common. We’re way past that. Now we have plenty of research and plenty of resources that we can all be doing better.”

The things that dental just can’t do

Maybe one of the biggest factors when comparing dental practice and hospital infection control measures is that dental practices simply have fewer resources.

“Larger facilities have a dedicated instrument reprocessing space, and they tend to have a dedicated person for that task,” Moore observes. “In dental, that instrument reprocessing is not given as high a level of focus as I’d like to see as it is in the hospital or ambulatory care setting. There are considerably more specific guidelines that are followed, even as far as instrument storage. In the dental setting, we say keep away from damp areas and under sinks and such, but within the hospital setting, there are more specifics. For instance, it has to be so many inches away from a wall; so many inches off the floor; et cetera. So, that’s getting really specific, but as far as instrument reprocessing and storage of instruments, I think medical has a higher level than we do.”

Even though dental practices have fewer resources to work with, they are still expected to maintain a similar level of protection.

“There’s no difference, just because you have a smaller setting, smaller equipment,” Spitzer says. “In hospitals, in the areas where they process instruments, the standard is that the dirty area should be physically separated by walls and doors from the clean areas. So, on the dirty side, they receive the dirty instruments, and there’s a lot of soil and germs and things flying through the air. And then on the clean side, they’re receiving clean instruments from the washers, and everybody’s hands are washed and they’re handling all these clean items. They’re not sterile, but they’re going to be putting them in the sterilizer. In dental office, you’ve got 1 tiny area, sometimes it’s just 10 feet of countertop, if you’re lucky, where you’re going from very dirty to very sterile.”

The best way for clinic staff to ensure a high level of safety is through education.

“People who know better are more likely to do better,” Spitzer says. “They need to look up the guidelines, get staff trained, and follow the guidelines. There are so many things that are simple, basic, and not expensive. This is not stuff that’s super expensive. It’s taking time to really clean the instruments properly and having a few simple things, like a drying drawer – a drawer that you can purchase and install that dries your instruments before they’re packaged and sterilized. This stuff is not billions of dollars. It’s a relatively modest cost. I think people overplay the cost of doing it the right way as an excuse for not doing it the right way.”

It may seem like hospitals demand a higher level of infection prevention than dental practices, but, for the most part, both environments need the same level of protection. And, while hospitals tend to have the resources to easily achieve that, dental practices must do at least as much with less.