The pandemic has made us hyperaware of disease transmission and infection control (IC) in our offices. But are we maintaining that vigilance?
To protect ourselves and patients from disease transmission, we must continue to revisit our existing infection control policies and make sure proper protocols and precautions are in place. We need to continue to observe these appropriate controls, including hand hygiene, respiratory hygiene, personal protective equipment (PPE) compliance, environmental surface disinfection, and up-to-date infection control training within our offices.
Since 1996 dental practices have abided by expanded Centers for Disease Control and Prevention (CDC) recommendations and best practices following standard precautions.1 Standard precautions include hand hygiene, use of PPE, respiratory hygiene, sharps safety, sterilization, environmental surface disinfection, and safe injection practices.1
The CDC continues to provide us with recommendations for controlling pathogen exposure and augmenting standard precautions by second-tier “transmission-based precautions.” Transmission-based precautions are put into place when treating patients infected with pathogens spread through contact, droplets, or airborne modes.2 Our long-established compliance with standard precautions may have put us in one of the best positions to protect ourselves and our patients from novel viruses. But are we staying compliant?
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Enter the Hawthorne effect
Evidence-based infection control protocols and procedures prevent the transmission of potentially harmful pathogens, but only with compliance. We are all exhausted, overworked, and uncomfortable. We have experienced PPE fatigue, the extra time needed to disinfect the operatories, and do I need to mention hand cramps from all the additional hand scaling? Have we become complacent now that more people are immunized?
The Hawthorne effect, first described and researched by Henry Landsberger, is “the change in behavior by subjects due to their awareness of being observed and is evident in research and clinical settings as a result of various forms of observation.”3 In clinical application, when we feel that our every move is being critiqued and observed by coworkers, bosses, and patients, our compliance with the protocol is on point. If no one is watching, however, adherence to the procedure decreases.4
Are we wearing PPE that fits properly? Are we wearing the proper masks consistently, even in the break room and reception areas? Are we allowing the disinfectant appropriate contact time? Are we washing our hands for the entire 20 seconds, even if no one is watching? It is vitally important that our IC procedures and policies are put into place and followed. Let’s revisit the measures we need to continue to enforce.
Reinforcing hand hygiene
Hand hygiene is one of the most basic and critical primary prevention actions to control infection transmission.5 When inadequate handwashing occurs, we transfer disease-causing pathogens to ourselves and our patients. Proper handwashing technique is a vital component in breaking the chain of infection.5
Always perform hand hygiene, whether that is an alcohol-based hand rub or soap and water.
Hand sanitizer that has 65%–90% alcohol as an active ingredient can be used and is preferred unless hands are visibly soiled. Soap and water wash must occur for at least 20 seconds. Health-care providers must sanitize hands before putting on and after taking off gloves. Alcohol-based rubs have better compliance and are less irritating to the skin than constant handwashing.1
Proper fit and use of PPE
Rotary dental and surgical instruments such as handpieces, ultrasonic units, air-polishing, and air-water syringes create a visible spray containing large droplets of water, saliva, blood, and microorganisms.6 The spatter travels a short distance and lands on dental health-care providers, nearby surfaces, and floors. The formation of aerosolized droplets from these dental instruments increases the potential transmission of SARS-CoV-2 virus.6
Interim recommendations for infection prevention and control have been guiding us on safely treating patients during the pandemic.7 PPE, including masks, protective goggles or face shields, overgowns, and gloves, protect the skin and mucous membranes from exposure to infectious materials. Overgowns must cover all exposed skin, and protective eyewear must protect the eyes above, below, and along the sides of eyewear. Personal eyeglasses are not considered adequate PPE. Use full-face shields if your glasses or loupes do not have protection on all sides.6 Dental personnel must adhere to proper fit and donning and doffing of all PPE before leaving the work area, operatory, instrument processing areas, and labs. Consider posting CDC donning and doffing charts and instructions for reference in your office.8
N95 masks: To wear or not to wear
Dental health-care personnel should follow the recommendations set forth by their state dental boards and local health departments for the most up-to-date information and guidance based on the transmission levels within their communities. You can find up-to-date COVID transmission data on the CDC Data Tracker.9
Suppose your area has substantial to high levels of transmission. In that case, the CDC recommends that you wear a NIOSH-approved N95 or equivalent respirator, along with use of high-evacuation suction, dental dams, and four-handed dentistry for aerosol-generating procedures.10 Before providing care, choose the correct mask based on its filtration, the procedure at hand, and possible exposure risk.
The CDC added respiratory hygiene/cough etiquette to its standard precautions in 2007,11 and the COVID-19 pandemic has reinforced the need to adhere to a simple set of rules. The second-tier transmission precautions include patient/provider mask-wearing within the health-care setting, proper PPE (including appropriate mask choice), social distancing, and containment of respiratory secretions of patients and dental health-care team members.1
Environmental surface cleaning and disinfection
Along with improper hand hygiene, another lapse in essential infection control is the failure to appropriately clean and disinfect environmental surfaces and devices.1 Contamination of these surfaces occurs by touch, splash, or droplets spread during patient care. It is imperative to clean and disinfect environmental surfaces without damage to the equipment from improper products and procedures. There are two categories of environmental surfaces: clinical contact surfaces and housekeeping surfaces.
Clinical contact surfaces are frequently touched—e.g., light handles, keyboards, bracket trays, and switches on equipment. Although clinical contact surfaces do not serve as a reservoir for pathogens, the pathogens may still have the ability to persist on these clinical surfaces for extended periods of time.12 More difficult-to-clean clinical contact surfaces (such as air-water syringes, computer keyboards, unit light switches, etc.) should be protected by plastic barriers before patient treatment. If the surface becomes contaminated, it must be cleaned and disinfected.13
Housekeeping surfaces, such as walls, floors, and sinks, carry less risk of disease transmission than clinical contact surfaces. They can be cleaned with soap and water and disinfected if visibly contaminated with blood.1
The fundamental step before disinfecting is cleaning the surface. Incomplete removal of soil and organic matter (blood and body fluid) will interfere with the effectiveness of the chemical disinfectant by protecting the pathogen from adequate exposure to the disinfectant or reducing the antimicrobial activity of the disinfectant.14 The CDC recommends selecting EPA-registered tuberculocidal disinfectants and following the manufacturer’s instructions for use of these products.13
Chemical disinfectants are categorized as high-, intermediate-, and low-level disinfectants based on their ability to destroy or inactivate pathogens.
High-level disinfectants destroy all microorganisms but not all bacterial spores. These disinfectants are used for immersion of heat-sensitive items and not used on environmental surfaces. They are very toxic and require special precautions for use. One example is glutaraldehyde.
Low-level disinfectants inactivate pathogens, such as HIV (human immunodeficiency virus), Staphylococcus aureus, pneumonia, and salmonella. Dental offices can encounter more virulent microorganisms that are more difficult to kill, especially viruses such as rhinovirus and any emergent viruses.
Hence, the CDC recommends using intermediate-level disinfectants that destroy most fungi and viruses. Intermediate-level disinfectants also kill the bacteria that cause tuberculosis (TB). TB is spread through airborne droplets and is very resistant to disinfectants. The ability of a product to kill TB bacteria is used as a benchmark to measure how effectively a disinfectant will kill all microorganisms. Any chemical used in a dental office must have the EPA-registered claim of being tuberculocidal. Tuberculocidal disinfectants are intermediate-level disinfectants. You can be confident that these disinfectants can kill and inactivate a broad spectrum of microorganisms. Pathogens such as bloodborne pathogens of hepatitis B, C, HIV, HPV (human papillomavirus), nonenveloped viruses such as rhinovirus (common cold), and norovirus can all survive for prolonged periods on surfaces.13
Updated infection control information is coming to us rapidly as new data is gathered. It can be a daunting task to keep up. Compliance is vital and achievable when the whole team is educated regularly and understands the expectations of the practice. The CDC recommends that every dental health-care facility assign an infection prevention coordinator who creates written infection prevention policies and procedures specifically for their setting and maintains education, training, and compliance documentation to safeguard office personnel and patients.1 We need to abide by infection prevention controls and recommendations and not get apathetic just because we are tired, stressed, and overworked.
- Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; October 2016. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf
- Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007;35(10 Suppl 2):S65-S164. doi:10.1016/j.ajic.2007.10.007
- McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. J Clin Epidemiol. 2014;67(3):267-277. doi:10.1016/j.jclinepi.2013.08.015
- Rezk F, Stenmarker M, Acosta S, et al. Healthcare professionals’ experiences of being observed regarding hygiene routines: the Hawthorne effect in vascular surgery. BMC Infect Dis. 2021:21(1):420. doi:10.1186/s12879-021-06097-5
- Alzyood M, Jackson D, Aveyard H, Brooke J. COVID-19 reinforces the importance of handwashing. J Clin Nurs. 2020;29(15-16):2760-2761. doi:10.1111/jocn.15313
- Dentistry workers and employers. United States Department of Labor. Occupational Safety and Health Administration. https://www.osha.gov/coronavirus/control-prevention/dentistry
- Guidance for Dental Settings: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. Centers for Disease Control and Prevention. Updated August 28, 2020. Accessed September 7, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#anchor_1604360679150
- Sequence for putting on personal protective equipment (PPE). Centers for Disease Control and Prevention. https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf
- COVID Data Tracker. Centers for Disease Control and Prevention. https://covid.cdc.gov/covid-data-tracker/
- Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf
- 1Oral health. Centers for Disease Control and Prevention. Updated September 15, 2021. https://www.cdc.gov/OralHealth/index.html
- Schneiderman MT, Cartee DL. Surface disinfection. In: DePaola LG, Grant LE, eds. Infection Control in the Dental Office: A Global Perspective. Springer, Cham; 2020:169-191. doi:10.1007/978-3-030-30085-2_12
- Molinari JA. Environmental surface disinfection considerations. ADA Center for Professional Success. 2020. https://success.ada.org/en/practice-management/dental-practice-success/dps-infection-control-2020/environmental-surface-disinfection-considerations
- Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. Centers for Disease Control and Prevention. Updated September 9, 2014. https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html
Editor's note: This article appeared in the print edition of December 2021 RDH.