Infections are a threat to the health, welfare and safety of individuals and groups in our community. As such, and in a perfect mechanical world, the threat posed by infective organisms would be managed through the usual hierarchy of controls developed to keep us safe.
- The first and best way to manage a threat of infection is elimination. The elimination of an organism ensures that there is no residual risk of infection from that organism. To date, the only organism that humanity has successfully eliminated is smallpox in 1980. Elimination is not possible with many other organisms as they are too widespread in geographic area and live in too many species and environments.
- The second-best way to remove a risk of infection from an organism is to substitute another organism in its place. This is unrealistic outside of limited areas of activity in food production such as the making of cheeses and the brewing of fermented drinks.
- The third best way of managing an infective organism is to isolate it within an area to which access is stopped. This it the objective of quarantine
- The fourth choice is to engineer controls using microbiology and gene manipulation; however, this is a high-risk activity as we have little idea of the unintended consequences of changing the structures of dangerous organisms.
- The fifth control method is to use administrative controls such as teaching people not to spit on the ground, not to cough or sneeze without an elbow crooked across the nose and mouth.
- Sixth and final is the wearing of personal protective equipment (PPE), gloves, masks and protective clothing. This the least effective control and thus, the most dangerous.
The most important of the controls used to control infection in dentistry is elimination through good hygiene and hard cleaning. However, we only do this to a very limited extent as we cannot kill every single virus or bacterium that can cause an infection. Despite our best efforts, the best we will do is reduce the number of dangerous organisms to a point where they cannot cause an infection.
The truth of the matter is that no one likes cleaning. It is time consuming, physically demanding and, to be blunt, boring. It is, however, our greatest weapon in stopping infections.
We often forget that the first thing that must be cleaned is ourselves. Whether dentist, dental assistant or another member of the team, all of us must keep fit and healthy so that our immune systems can defend us against harmful organisms. We assist our bodies in this by maintaining good personal hygiene in all aspects of our dress and bearing.
Wash hair, hands and bodies, usually through showering under running water whilst using good quality cleaners supplemented by towelling all dry is vital. The towel not only absorbs the water on your skin and in your hair, but in doing so, it drags the residual loading of organisms into the towel where, where, if it is hung up to dry properly in sunlight coming through a window, the bulk of the organisms will then die. Thus, good personal hygiene is not only showering and washing, it is the management of the items you use in that process as well.
The care with which we wash and dry ourselves needs to be repeated for the clothing we wear and how we wear our hair and nails. Clean clothing, that has been properly washed and dried, and hair that is securely tied up or kept short is essential, as are short and clean natural nails.
If we have washed, dried and dressed ourselves in this way, then we are able to go to work in a dental practice knowing we have taken the first step in effective infection control.
On arrival at work the first things to be done is to take off outer clothing and put them and our personal belongings in our locker along with rings, wrist watches, bangles and all jewellery that will hold colonies of organisms. Following this, we then change into scrubs, which must never be worn outside of the practice or even in not clinical areas such as lunchrooms and perhaps even receptions. Now, we can begin the process of ensuring infection control in the practice.
This involves the effective cleaning of the treatment rooms and all other areas of the practice. This cleaning should start in the cleanest parts of the practice and move into those areas that are the dirtiest. Thus, we might begin cleaning from those areas where people seldom go or seldom reach. We start from the remotest part of the practice and the highest parts of the practice and we clean down and inwards to the dirtiest, which means that we end up cleaning into the dirty end of the steri-room, which we clean last into the dirty sink.
The same process is applied to treatment rooms where we clean the light fittings and overhead structures and the cupboards and benches back to the dental chair and then from the middle of the chair to the head and foot ends of the chair, both of which will be the dirtiest parts.
Once we have finished our environmental clean, which should include all floors as well, we then prepare the room for work. This might entail the use of barrier devices, but remember, barrier devices are a form of PPE and are the lowest level of control you can use. The cleaning of all surfaces, controls, grips and handles is the far more important control method as, although it does not completely eliminate all organisms, it eliminates so many of them they cannot cause an infection.
All of this is done with frequent handwashing to ensure what we do not transfer organisms from one area or from one person to another.
Now, the dental instrument packs and other specially sterilised equipment can be brought in, opened and used.
Once the dental procedure is completed, aother environmental clean of the areas within which the treating dental team and the patient moved is required. It is vital that this is done as, whilst we may be in good health and we have good hygiene and have taken steps to limit the transfer of organisms ourselves, the same is not true of the patient. The room, chair and all surfaces must now be cleaned. This is best done using two vital things: one, a good neutral detergent, and two, elbow grease and lots of it.
One of the commonest problems seen by Cynergex when visiting practices is the failure to actually clean surfaces, equipment and controls. This failure is not due to staff not rubbing down the surface using the approved cleaning product. It is due to the wiping not being sufficiently hard enough to physically dislodge the organisms on the surface. These organisms stick to a surface they contaminate and one there they cannot risk being blown off by a slight breeze or a passing human. They adhere to the surface using chemistry. The purpose of the detergent you use is to loosen or breakdown this chemical binding so that a good rub with plenty of elbow grease then removes the bulk of the organism resulting in a reduction of the threat it can cause infection. This is as close to elimination we can get in infection control and it depends on three things, two of which, a good detergent and elbow grease, we have now discussed.
The third thing vital to ensuring good infection control standards in any dental practice is effective supervision that objectively verifies that cleaning has been done. How does a good practice manager know the cleaning has been effective? That is effective cleaning has been accomplished and the organisms eliminated or reduced. This is not the same as verifying that someone has conducted a cleaning of the room or chair or surfaces because, as we have already noted, such cleaning does not remove or eliminate the organisms. The effective verification of cleaning effectiveness is the biggest gap we currently face is infection control.
The Cynergex Infection Control course is designed to address the problems of verification and effective supervision as well as providing practical help in easy solutions to the problem of maintaining high standards of cleaning in the dental practice. As we have noted, good infection control relies on good cleaning products used with vigour and elbow grease within a system that is well supervised and where the practice verifies that effective cleaning is taking place.
 National Institute of Allergy and Infectious Diseases, Smallpox, https://www.niaid.nih.gov/diseases-conditions/smallpox, accessed 1 February 2020. The Smallpox pathogens Variola Major and Minor are maintained in two level five containment facilities, one in Atlanta, Georgia, US and one in Koltsovo, Siberia, Russia.