In the first 5 weeks of 2015, 121 people were reported to have measles in the United States—the majority a result of a multistate outbreak related to the Disneyland theme park in Southern California. According to the Centers for Disease Control and Prevention (CDC), the United States had already seen a record number of cases during 2014—644 cases, across 27 states—the result of a large outbreak among unvaccinated Amish communities in Ohio, as well as travelers from the Philippines, which experienced its own large outbreak. The 644 cases documented in 2014 marked the highest number of cases in the United States since measles was declared eliminated in 2000.
With this in mind, infection control should be high on an orthodontic practice’s list of priorities. However, measles is only one of the risks to patients and staff during an office visit. Orthodontic Products talked to Jackie Dorst, RDH, BS, an expert on infection prevention, instrument sterilization, and OSHA safety. She has been a featured speaker at meetings of the American Association of Orthodontists (AAO) and the American Dental Association, and is a member of the Organization for Safety, Asepsis and Prevention (OSAP) and the Association for Professionals in Infection Control and Epidemiology.
Orthodontic Products: Where are the greatest risks of infection to be found in the orthodontic practice?
Jackie Dorst: Diseases that are transmitted in saliva splatters, splashes, and aerosols are a greater risk during orthodontic treatment than the bloodborne pathogens. As most orthodontic procedures are noninvasive, normally there is very little blood exposure during orthodontic procedures. However, many infectious microorganisms are transmitted in saliva, including measles, mumps, norovirus, staphylococcus, streptococcus, influenza, infectious mononucleosis, herpes, cytomegalovirus, chicken pox, colds, and meningococcal disease. Thus, saliva contamination on surfaces such as cure light handles, air-water syringes, intraoral scanners, cheek retractors, and photographic mirrors have the potential for transmitting infectious diseases from one patient to another if proper infection control protocols are not used.
OP: What are some steps a practice can take to rectify these issues?
Dorst: Infection control training for all clinical orthodontic team members is necessary to prevent disease transmissions. Orthodontic assistants and the orthodontist must have a clear understanding of proper disinfection technique, use of barriers, and orthodontic instrument sterilization. Education and training provide the clinical team comprehensive information to evaluate infection control products and the correct methods for use. Infection control breaches frequently occur when the orthodontic team doesn’t have up-to-date education and training.
OP: Why does a practice need an infection control protocol?
Dorst: Infection control protocols, such as checklists and monitoring, ensure that all infection control and sterilization procedures are done correctly and are effective. For instance, the ortho infection control protocol must identify where and when barriers are used and how disinfectants are used to clean and disinfect contaminated surfaces. Without an infection control protocol and monitoring, a new orthodontic assistant might improperly use a disinfectant because he/she applied procedures applicable to a different disinfectant used in his/her previous office. Some disinfectants require a 3-minute wet time, while others require a 10-minute wet time to kill microorganisms. Too little wet contact time results in ncomplete disinfection and the potential for disease transmission from one patient to the next patient.
Infection control protocols specify the correct steps and methods for decontamination in each area of the orthodontic practice—from the clinical treatment area and records room to the sterilization room and laboratory. Monitoring—such as the spore tests on sterilizers—verifies and provides documentation that equipment is working properly and that all team members are using the correct protocols.
OP: What steps can staff take to minimize disease transmission risk during clinical activities in the practice?
Dorst: The CDC Guidelines list the steps to prevent disease transmission in oral health facilities:
- Hand hygiene
- Proper use of barriers
- Proper use of disinfectants
- Proper instrument sterilization
- Aseptic technique
The CDC Guidelines for Infection Control in Dental Health-Care Settings—2003 are the current standard for oral healthcare infection control in the United States. The CDC Guidelines are included as the infection control standard in most state dental practice acts and is used by state dental board inspectors should there be an infection control breach. All orthodontic offices should have a copy of the CDC Guidelines.
The book From Policy to Practice: OSAP’s Guide to the Guidelines, from OSAP, is an excellent resource and training workbook for the orthodontic team. The workbook provides detailed instructions and photos on all steps of an effective infection control protocol in dental offices. In addition, the AAO has an on-demand infection control webinar for the AAO Orthodontic Staff On-line Study Club.
Infection control is complex, and frequently the orthodontic team is confused by product labels, conflicting information from different sources, and lack of time for training. The orthodontic clinical coordinator must have a comprehensive understanding of infection control standards so that he/she can educate new team members and determine the correct IC protocols for the practice.
OP: When talking about infection control in an oral healthcare setting, often the focus is on the clinical environment. What should practices do to mitigate or control risk in common areas like the reception area?
Dorst: The recent measles infections, which originated with an infected amusement park attendee, highlight the need for infection control in the nonclinical areas of the orthodontic practice. As a start, post a patient notice at the front desk, as seen in Figure 1.
Alcohol hand sanitizer, tissues, and a trash receptacle for used tissues should be available at the front desk, as well as pediatric masks for patient siblings arriving at the office with respiratory infections. These masks can reduce the potential spread of respiratory infections. In addition, an IR thermometer or disposable thermometer should be available to determine if a patient has a fever. Patients with a temperature above 100° should be rescheduled.
Digital game devices and toys in the reception area, kids room, and on-deck area should be cleaned and disinfected. In the TC room, if a sink is not available, then the treatment coordinator must have alcohol-based hand rub for the doctor to use prior to gloving for the new patient exam. The new patient exam instruments should be in a sterile instrument package.
[sidebar float=”right” width=”300″]An Infection Control Partner
This May, the Organization for Safety, Asepsis and Prevention (OSAP) will have its 2015 Symposium—titled “Infection Control—Gaining the Edge.” Designed for members of the dental industry, the symposium focuses on the current and emerging issues relating to infection prevention and safety in oral healthcare settings. Orthodontic Products spoke to Therese Long, MBA, CAE, executive director of OSAP, to learn more about the upcoming symposium and what the OSAP has to offer orthodontists.
OP: Tell us about OSAP and the upcoming symposium.
Therese Long: Celebrating over 30 years of service to the worldwide dental community, OSAP is a growing community of clinicians, educators, policymakers, consul- tants, and industry representatives who advocate for safe and infection-free delivery of oral healthcare. OSAP focuses on practical strategies to improve compliance with safe practices and on building a strong network of recognized infection control experts. OSAP offers an extensive online collection of resources, publications, FAQs, checklists and toolkits, and two annual conferences to help dental professionals ensure that every visit is The Safest Dental VisitTM for patients and the dental team.
The symposium is one of OSAP’s two yearly conferences. It is advanced training for dental and orthodontic clinical coordinators who must have a comprehensive understanding of infection control standards. The 2015 symposium is scheduled for May 28 to 30, 2015, in Baltimore, at the Hyatt Regency Inner Harbor.
The goal of the 2015 symposium is to create and empower champions in the safe delivery of oral healthcare through didactic, interactive, and networking sessions. The symposium will address evolving guidance and emerging issues while delivering the most relevant science, policies, and procedures for patient and provider safety and infection control and prevention. The symposium also will feature tours of the National Museum of Dentistry as well as a fun boat tour of the Baltimore harbor.
OP: Besides the lectures, what other learning opportunities will be available for symposium attendees?
Long: The symposium will have “Special Interest Groups (SIGs)”—small sessions during which attendees can really drill down on topics that are the most important for them. The more relaxed, smaller breakouts are designed to foster a lot of Q&A and discussion. Additionally, the conference will have an “Ignite” session that features a rapid succession of speakers on hot topics so attendees can get the bottom line on numerous topics in a short period of time. Attendees who are educators or consultants also can participate in preconference sessions that focus on their specific infection control issues. Finally, attendees can visit the vendor fair to learn about exciting new infection control and patient safety products.
OP: If someone has never attended the OSAP Symposium, why should they attend now?
Long: The program is highly relevant and designed to provide an amazing environ- ment to really learn and absorb key takeaways on all the critical emerging issues, as well as expand one’s network of peers for long-term help and support. Plus, the venue in 2015 in right across the street from Baltimore’s famous and beautiful harbor and walking distance to innumerable world-renowned museums, the aquarium, shops, restaurants, and other activities. Attendees will be able to enjoy the best of all worlds—inexpensive transportation with the symposium’s proximity to BWI Airport and public transportation, the perfect time of year for visiting the Mid-Atlantic, world-class education, and conference attendees who are passionate about infection control.
OP: Who from the orthodontic practice should attend the OSAP Symposium?
Long: The ortho clinical coordinator, so she/he will be able to educate team members and determine the correct infection control protocols for the practice.
OP: If someone can’t attend the OSAP Symposium, what other educational opportunities or resources does OSAP offer?
Long: There are so many—visit osap.org, click on “Knowledge Center,” and you’ll see tabs for continuing education, checklists, toolkits, and a vast array of resources. It is highly advisable that every orthodontic practice obtains a membership in OSAP to be kept apprised of the evolving field of infection control. For a very modest fee, membership offers practices an “infection control partner” as OSAP provides the trusted advice and resources that help practices deliver the safest visit for every patient and team member…because safety matters. OP[/sidebar]
OP: What can staff do to ensure that patients know infection control is a ?priority in the practice?
Dorst: Patients are aware through the media and education of infection prevention protocols. Letting patients see IC procedures, such as opening a sterile instrument cassette or pouch and the donning of PPE, are visual reassurances for orthodontic patients and parents. The use of correct terminology when discussing instrument sterilization and disinfection protocols indicates the level of training and professionalism of the orthodontic team.
For patients knowledgeable about infection control protocols, such as a dental hygienist or nurse, it is important that they observe correct IC protocols such as the color change on sterile package indicators and proper donning of PPE. Should a patient/parent observe a gap in the infection control protocols, they will immediately wonder what else is maybe lax in the practice.
OP: What type of communication should be going on between staff and patients with regards to infection control?
Dorst: New patients/parents who are anxious about disease transmission and infection control will normally ask questions on their first visit to the office. Normally, they ask questions of the treatment coordinator. Many medical and orthodontic patients are hesitant to ask the doctor questions about the practice. The treatment coordinator must provide knowledgeable answers to the patient’s questions. This is one of the reasons I request TCs and front desk team members attend my in-office IC/OSHA training. The entire team must have a clear understanding of infection control and sterilization should a patient ask questions.
OP: Are there any additional protocols that orthodontic practices should have in place for when a communicable disease is in question?
Dorst: Standard precautions provide protection against the transmission of infectious diseases. Infectious patients with fever or respiratory infections should be rescheduled because of the risk of airborne transmission, especially in the open-bay clinic design of most orthodontic offices. Should an infectious patient need to be seen for an emergency, such as a poking wire, then schedule the patient at the end of the day or during lunch period. Do minimal treatment for patient comfort. Longer treatment procedures can wait until the patient is noninfectious. This helps reduce potential exposure to other patients and the ortho team.
OP: In your experience, what is the most overlooked infection control issue among orthodontic practitioners? What can they do to rectify it?
Dorst: Unpackaged orthodontic instruments. Place orthodontic instruments in sterile packs prior to sterilizing. Wrap cassettes in CSR wrap, include an internal indicator, and seal with autoclave tape prior to sterilization. Many orthodontists store and transport unpackaged instruments after sterilizing. These unpackaged instruments can potentially be contaminated as soon as the instruments are removed from the sterilizer. Sterilizing orthodontic instruments in a sterile package ensures sterility until the instruments are used for patient treatment.
OP: How often should a practice ?evaluate its infection control protocols? Who should be in charge of tracking ?these efforts?
Dorst: The clinical coordinator (leader) is normally the best choice for the infection control leader position. He/she must be a team member who understands orthodontic procedures, equipment, and schedules. The practice’s infection control protocols should be reviewed at least annually and every time that a product or procedure is changed.In addition, if new equipment is added, then the entire clinical team must receive training on the manufacturer’s instructions for cleaning, disinfection, and sterilization—the manufacturer’s IFUs (instructions for use). Innovative new orthodontic treatment procedures, digital equipment, and instrumentation present infection control challenges. But an inspired infection control leader ensures safety for patients and the orthodontic team. OP