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Infection control's bottom line

Dec. 1, 2010
When the OSHA Bloodborne Pathogens Standard was first enacted in 1991, several studies were conducted ...
Balancing safety, 'green practices,' and cost effectiveness

by Mary Govoni, CDA, RDA, RDH, MBA

When the OSHA Bloodborne Pathogens Standard was first enacted in 1991, several studies were conducted to substantiate the cost of infection control or prevention procedures for dentistry. Although there was some variation, the average cost was estimated to be about $15 per patient visit. This number included the cost of disposable items and barriers; personal protective equipment, such as gloves and masks; replacement and repair of handpieces due to required sterilization; the cost of sterilization equipment; and the use of disinfectants.

There was some discussion years ago about adding an "infection control" fee to dental procedures to help to cover these costs. But it was determined that insurance plans would not pay this fee, since they believed that infection control costs were an inherent part of all dental procedures. Most dental practices believed that it would be an administrative hardship to try to collect these fees directly from the patient. This concept was modeled after the medical health care delivery system, where billing for services is itemized, including consumable items used for procedures or surgeries. This model was determined not to be appropriate for the delivery of dental health-care services.

We now know from 20 years of experience that our efficiency was negatively impacted initially by the new requirements, and that our supply costs in many cases increased significantly. Infection prevention has now, for the most part, become so second-nature that we don't always think of the financial impact of these procedures and protocols. In this economic crunch that we find ourselves in, it makes sense to revisit these costs to determine whether there are ways to decrease some of the costs without negatively impacting the bottom line.

This article examines three categories of expenditures – disposables and consumables, equipment, and staff time – and make recommendations for cutting costs without compromising quality of care.

While there is a growing movement within dentistry to "go green" and use less disposable and more reusable items, this may or may not be the most effective strategy in terms of the bottom line and patient safety.

Is cloth really more efficient than disposable products?

Some experts, for example, recommend reusable cloth pouches for instrument packaging prior to sterilization. While this may save money long term and cause less waste from disposing of paper pouches and wraps, these cloth packs must be laundered frequently to keep them looking presentable to patients who see them. After a number of sterilization cycles, the cloth pouches tend to discolor, making their appearance less than appealing to patients (and team members as well). This discoloration may also lead to staining of the instruments. During a time when we need to be more effective than ever with our internal marketing strategy, having patients think that instruments are stored in "dirty" bags is counterproductive.

Another "green" recommendation is to use reusable cloth barriers on equipment rather than disposable plastic barriers. Again, it may not be the most practical strategy, since the barriers must be washed after each use. In an average practice that may see 20 patients per day, that adds up to a great deal of laundry that must be done, using soap, water, and electricity. Some of these cloth barriers may also be porous, which would allow contamination from spatter or aerosol to potentially soak through onto surfaces. If that is the case, the surfaces must be disinfected underneath the barriers, which increases the time necessary to turn around a treatment room, and uses more chemicals (disinfectants) and applicators (gauze or paper towels). While switching to reusables may be effective, it should be closely evaluated for hidden costs of reprocessing these items.

When selecting disinfectants and ultrasonic cleaning solutions, choose a product that is effective and meets your specifications. But also consider products that have the least amount of packaging. This not only decreases their cost, but also makes them more environmentally friendly. In addition, selecting instrument cleaners that are tablets or powders can be less expensive, due to decreased packaging. These products also require less storage space, which always seems to be at a premium in dental facilities. Purchasing liquids that come in concentrated forms also saves on packaging.

For the sake of this article, dental handpieces and instruments, ultrasonic scalers, sterilizers, and operatory furniture are considered equipment in dental facilities. These are items that require substantial investments and should be meticulously maintained in order to maximize their useful life. Always follow the manufacturer's directions for handpiece maintenance, cleaning and use of sterilizers, and maintenance of ultrasonic and piezoelectric scalers. Be aware of manufacturer's recommendations for or against using surface disinfectants on some equipment. In addition, follow the manufacturer's guidelines for cleaning and sterilizing ultrasonic inserts. Protecting the inserts, as well as hand instruments can be accomplished by placing these items in cassettes for cleaning and/or sterilization. A dental facility should establish a schedule for cleaning and maintenance on all equipment.

Dental operatory equipment, such as patient chairs, can last much longer if the manufacturer's instructions for cleaning and disinfection are followed. Barriers help to protect and preserve upholstery. High alcohol disinfectants may cause the upholstery to dry out and crack. Be sure to read and follow the product instructions for use as good maintenance prevents costly repair bills.

Infection control as a time management issue

The last thing to consider is efficiency, as well as how inefficiency affects the bottom line. In a busy practice, preparing instruments for sterilization can be time consuming if the facility is breaking down trays, placing individual instruments in the instrument cleaner (ultrasonic), sorting, and then packaging prior to sterilization. Investing in an instrument management system, such as cassettes, can decrease the amount of time spent on instrument handling by five to 10 minutes per procedure and provide a safer environment for the team members.

When instruments are packaged in a cassette, they do not have to be placed individually in the ultrasonic, and team members are less likely to poke themselves with the contaminated, sharp ends of the instruments. The entire cassette goes in, saving valuable time. More time is saved when the instruments are packaged, since the entire cassette can be placed in a pouch or wrapped, rather than having to sort instruments to put them back together in a specific procedure set-up and then packaging them. This also extends the useful life of the instruments as well as reduces the number of missing instruments.

The less time team members have to spend reprocessing instruments, the more time they have to interact with or provide services to patients. The investment in a cassette system can be quickly returned to the practice in increased production.

Also, investing in storage tubs to organize materials and other items needed for specific procedures can increase efficiency. When setting up an operatory for a procedure, an instrument cassette and a procedure tub are retrieved from a storage area. For the most part, the room is ready, except for some disposable items. This saves a tremendous amount of time retrieving items from drawers or other storage areas each time a treatment room is set up. It also saves time if the procedure changes, as it frequently does during treatment.

For example, if the patient was scheduled for a filling, but it is determined that core build-up and crown are needed, the tubs can be easily and quickly switched to have the appropriate materials and items available and cross contamination by reaching into drawers to retrieve items can be minimized.

The maintenance and periodic cleaning of waterlines is another area of infection prevention that lends itself to greater efficiency. Utilizing waterline cleaners that must be left in the unit for long periods of time and then purged back out is time consuming. Continuous-use products for water line maintenance can be added into the water bottle at each refill, which saves valuable chair time without compromising effectiveness.

Additionally, utilizing a complete dental unit water line system that includes both a cleaner as well as a maintenance product could help you minimize your cost of delivering potabable drinking water to your patients. In addition, it protects your equipment and ultrasonic scaling units, extending their useful life.

Watching the bottom line is not just about buying the least expensive products. While it is important to compare products and their costs, it is also very important to invest in systems and protocols that will assist in maintaining existing equipment and decrease the amount of needed repairs or replacement. It is also very important to take measures that protect you, the staff, and your patients and to evaluate efficiency and effectiveness in the delivery of care. Take the time to evaluate supply costs, implement scheduled maintenance procedures for equipment, and assess the efficiency and safety of procedures.

If you do, you may have reason to celebrate increases in the bottom line, without compromising the high quality of your infection prevention procedures.


Mary Govoni, CDA, RDA, RDH, MBA, is the owner of Clinical Dynamics, a consulting company based in Michigan. She is a member of the Organization for Safety and Asepsis Procedures. She can be contacted at [email protected] or visit

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