Journal of Hospital Infection (2009) 71, 353e358

Available online at www.sciencedirect.com

www.elsevierhealth.com/journals/jhin

Management of infection control in dental

practice
A. Smith a,*, S. Creanor b, D. Hurrell c, J. Bagg a, M. McCowan d
a
Infection Research Group, University of Glasgow Dental School, Faculty of Medicine, Glasgow, UK
b
Biostatistics & Epidemiology Group, University of Plymouth, Tamar Science Park, Plymouth, UK
c
HealthCare Science Limited, Bury Mead Road, Hitchin, UK
d
Infection Control, Golden Jubilee National Hospital, Clydebank, UK

Received 24 October 2008; accepted 7 November 2008

Available online 21 January 2009

KEYWORDS Summary This was an observational study in which the management pol-
Cleaning; icies and procedures associated with infection control and instrument de-
Decontamination; contamination were examined in 179 dental surgeries by a team of
Dental instruments;
trained surveyors. Information relating to the management of a wide range
Medical devices;
Quality management
of infection control procedures, in particular the decontamination of dental
systems; Sterilisation instruments, was collected by interview and by examination of practice
documentation. This study found that although the majority of surgeries
(70%) claimed to have a management policy on infection control, only 50%
of these were documented. For infection control policies, 79% of surgeries
had access to the British Dental Association Advice Sheet A12. Infection con-
trol policies were claimed to be present in 89% of surgeries, of which 62%
were documented. Seventy-seven per cent of staff claimed to have received
specific infection control training, but for instrument decontamination this
was provided mainly by demonstration (97%) or observed practice (88%).
Many dental nurses (74%) and dental practitioners (57%) did not recognise
the symbol used to designate a single-use device. Audit of infection control
or decontamination activities was undertaken in 11% of surgeries. The ma-
jority of surgeries have policies and procedures for the management of in-
fection control in dental practice, but in many instances these are not
documented. The training of staff in infection control and its documentation
is poorly managed and consideration should be given to development of
quality management systems for use in dental practice.
ª 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.

* Corresponding author. Address: Infection Research Group, Level 9, Glasgow Dental Hospital and School, 378 Sauchiehall Street,
Glasgow G2 3JZ, UK. Tel.: þ141 211 9747; fax: þ141 353 1593.
E-mail address: a.smith@dental.gla.ac.uk

0195-6701/$ - see front matter ª 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2008.11.026
354
Introduction
Infection prevention and control are key elements
in providing a safe environment for patients and
staff within a dental practice.1e5 Recent media in-
terest and publications have created heightened
concern.6 The discovery of vCJD and the potential
for spread of not only this agent, but also blood-
borne viruses and other infectious agents, via inad-
equately decontaminated instruments has also led
to increased concerns.
The benefits of a well-managed infection
prevention and control system in any premises
delivering healthcare have become both a public
and political prime concern.5,7 An appropriately
managed infection prevention and control service
should share the responsibility across the practice
staff whilst maintaining accountability, and provide
quality assurance that instruments are effectively
cleaned and sterilised. There are many sources
of infection control advice available, which can
be adapted and reconfigured to improve the
service delivery and assist the dental practice in
delivering quality infection control in an appropri-
ately risk-assessed environment.1,2,8e11
The British Dental Association (BDA) Advice
Sheet A12 on infection control in dentistry pro-
vides broad advice on the roles and responsibili-
ties in relation to management of infection
control.1 All members of the dental team must
know who is responsible for ensuring that certain
activities are carried out and to whom they should
report any accidents or incidents. The individual
practitioner must ensure that all members of the
dental team understand and practise these proce-
dures routinely, have been appropriately trained
and have demonstrated competence in particular
procedures. This must be documented. There
are also technical standards for Local Decontami-
nation Units (LDUs). A senior member of staff with
documented responsibilities for infection control
and the decontamination of dental instruments
must be nominated to manage these activi-
ties.9,12e23 A job description should set out these
responsibilities to manage infection control in ac-
cordance with legal requirements and national
standards.9,12e22 The surgery should also have
documented defined accountability for infection
control and the various stages in decontamination
of dental instruments (including device acquisi-
tion and disposal). The surgery should have
written policies and procedures that define, docu-
ment and control the various stages involved in
managing the risks of infection. These should be
readily available to all relevant staff in a surgery.
A. Smith et al.
There should also be access to current legislation
and guidance relevant to infection control.
This requires appropriately trained staff and
record-keeping systems that are regularly
audited.9
Previous attempts at investigating management
of infection control in dental practice have relied
on questionnaire studies with their attendant
shortcomings.23 In order to address these shortcom-
ings, we have previously described a methodology
for a large observational study of decontamination
of dental instruments in general dental practice.24
The aim of this study is to report in detail the
management of infection control and instrument
decontamination in a large cohort of dental prac-
tices that were visited between January 2003 and
March 2004.
Methods
Survey methodology
This has previously been reported in detail.24 In
brief, the study population comprised all general
dental practitioners in Scotland with a National
Health Service (NHS) list number (N ¼ 837). This
list was the basis for randomly selecting practi-
tioners to survey.
A two-stage proportional stratified random sam-
pling method was used to identify which surgeries
were to be surveyed. First, practices were ran-
domly selected in proportion to the distribution of
practices within each of the health boards. Then,
if there were more than one dentist within
a selected practice, simple random sampling was
used to identify a single dentist within the
selected practice to be approached. The surgery
that the dentist worked from and its associated
decontamination facilities were the subject of the
survey. A total of 184 surgeries were surveyed.
Data collection
Each surgery was surveyed by a team of two, an
infection control/decontamination expert and an
experienced dental practitioner. The survey team
interviewed the dental practitioner and dental
nurse, reviewed documentation relevant to the
survey and recorded the physical layout of the
premises. The decontamination processes, policies
and procedures available to the dental surgery
staff were viewed directly by a member of the
survey team. All relevant data were recorded on to
data collection forms prepared for automated
Infection control in dental practice
reading.24 The survey visits ran from January 2003
until the end of March 2004.
Technical requirements and guidance
The data collection forms for the survey were
based on a number of technical requirements and
guidelines.1,12e20 In addition, data were collected
to examine compliance with a number of legal re-
quirements designed to ensure that appropriate
facilities and management processes were in place
in surgeries. These include the Consumer Protection
Act, The Medical Devices Regulations 2002, The
Health and Safety at Work etc. Act 1974 and Man-
agement of Health and Safety at Work Regulations
1992.12,13,25,26
Results
Data were available from 179 surgeries for analy-
sis. In the surgeries surveyed, the number of staff
that worked in the selected surgery was 1e9 for
dental practitioners, 0e1 for community dental
officers, 0e1 for vocational trainees, 1e7 for
dental nurses, 0e5 for trainee dental nurses, 0e5
for hygienists, 0e4 for receptionists and 0e4 for
cleaners. Infection control was included in the job
description of 13% of dentists and 46% of dental
nurses. In 7% of practices there was one or more
member of staff whose sole or principal duty
involved the cleaning and sterilising of dental
instruments. In those practices without a dedicated
member of staff these tasks were undertaken by
dental nurses. Additionally, 42% of dental practi-
tioners, 38% of dental hygienists and 2% of
ancillary staff undertook decontamination of in-
struments. In no surgery were dental technicians
undertaking decontamination of instruments.
Infection control management and decon-
tamination policies
A policy is used to describe a statement of intent
and/or objectives. Of the 70% of surgeries with
a management policy for infection control avail-
able within the practice, only 50% were docu-
mented. With regard to policies for infection
control, the BDA Advice Sheet A12 was available
in 79% of the surgeries visited, of which 45% used
the BDA Advice Sheet A12 unmodified as their
policy. In 16% of surgeries there was effective
policy control of infection control documentation
(for example unique numbering of policies). Al-
though 73% of surgeries had a system in place to
ensure that all staff were kept up to date with
355
changes in policy, only 26% had a documented
system for ensuring that this took place. Within
the practice, 51% had a monitoring system to
ensure that infection control procedures were in
line with current guidance.
In 23% of surgeries there was a policy giving
guidance on when to choose single-use as opposed
to re-usable instruments, when both were com-
mercially available. For 47% of surgeries there was
a policy on the re-use of devices labelled as single
use, of which 37% specified that re-use was never
allowed. Re-use of matrix bands was undertaken in
34% of surgeries, re-use of endodontic files was
undertaken in 87% of surgeries and re-use of
impression trays was undertaken in 59% of surger-
ies. Fifty-one percent of surgeries had a written
policy describing the method of cleaning to be
used for re-usable medical devices.
Infection control procedures and work
instructions
Procedures and work instructions provide step-by-
step instructions of how a particular task is to be
carried out. Within the surgeries surveyed, 89%
had infection control procedures, of which 62%
were documented.
Infection control staff meetings
Regular specific infection control meetings were
held by 16% of practices. Of these, 22% had
annual meetings and 56% had meetings only
when required. At routine staff meetings, 89%
discussed infection control, but only 46% of staff
meetings were minuted and 48% recorded de-
cisions taken.
Staff training
The ability of staff to recognise safety symbols on
medical devices is good practice.27 The knowledge
of dental staff in the recognition of common sym-
bols is summarised in Figure 1.
Seventy-seven per cent of staff had received
specific infection control training. For the dental
practitioners that had received such training, 74%
had attended Section 63 postgraduate courses
organised by NHS Education for Scotland. For the
dental nurses who had received specific training,
66% had been taught at Scottish Vocational Qual-
ification (SVQ) level. In 31% of surgeries there were
documented training records for each member of
staff and training was reviewed on a regular basis
in 58% of surgeries.
356
50
45
40
35
30
25
20
15
10
5
0 Audit of infection control activities had been
Dental nurse Dentist
Figure 1 Recognition of single-use (white bars) and
use-by (black bars) symbols by dental staff.
Sixty-two percent of surgeries had procedures in
place to ensure that staff training occurred in the
documented procedures used as part of their
routine work activity on dental instrument de-
contamination. Compliance with these procedures
was formally monitored in 21% of surgeries. Staff
training in decontamination was provided mainly
by demonstration by other practice staff (97%)
and/or by observed practice (88%).
Hand washing
Hand washing is a key component of infection
control policies. A procedure for hand washing was
available in 53% of surgeries, of which 32% were
documented. Hand washing was part of training for
all practice staff in 41% of surgeries and in 53% of
surgeries for clinical staff only. The majority of
surgeries (84%) used surgical hand scrub alone
and/or alcohol gels/solutions (22%), liquid soap
(20%) and bars of soap (4%). Re-usable nail brushes
were present in 22% of surgeries.
Waste disposal
In 93% of surgeries there was a waste disposal
policy, of which 53% were documented. Puncture-
proof containers were used for the disposal of
sharps in 99% of surgeries, all of which were
compliant with BS7320. Partly used local anaes-
thetic cartridges were disposed of in a sharps box
(63%), special waste box (24%) or yellow waste bag
(5%). Extracted teeth were disposed of in a yellow
waste sack (58%), orange waste sack (11%), sharps
box (8%) or black waste sack (1%), or sent to a dental
school to be used for training purposes (25%).
A. Smith et al.
Traceability
No surgery kept records that enabled traceability
of instruments to the patient. However, 1% of
surgeries kept records that enabled tracing of
instruments through the cleaning and/or the
sterilisation process. Most surgeries (99%) decon-
taminated equipment prior to sending it for repair,
of which 77% issued a written statement with the
equipment to state that this had been performed.
Audit of infection control policies and
procedures
undertaken in 11% of surgeries, of which 54% fed
back results to all staff and 46% defined timescales
for remedial action.
Staff health and safety
All staff had access to personal protective equip-
ment. Access to individual items of protective
equipment occurred in 97% of surgeries for eye
protection, 98% for surgical masks, 99% for gloves
and 35% for waterproof aprons. The majority of
surgeries (98%) had no contract for laundering of
staff uniforms, which were usually processed in
a domestic washing machine (99%).
All staff involved in the decontamination of
dental instruments had been offered immunisation
against hepatitis B. However, staff in 59% of
surgeries commenced work decontaminating den-
tal instruments prior to completing a full course of
hepatitis B immunisation. New staff had a health
screen in 49% of surgeries.
In relation to the Control of Substances Hazard-
ous to Health (COSHH) regulations, 69% of surgeries
had safety data for each chemical used. Sixty-one
percent of surgeries had a safety policy to deal with
any spillages or leakages of chemicals which took
into account the potential chemical or microbio-
logical hazards. In 42% of surgeries, manufacturers’
instructions were followed when decontaminating
dental instruments used in the surgery.
Discussion
When compared with earlier literature this survey
has shown much improvement in certain aspects of
infection control and instrument decontamination
in dental practice. For example, the availability
of personal protective equipment, such as gloves
and eye protection, has increased over the last
decade.23 It is also reassuring that all practices
Infection control in dental practice
offered hepatitis B immunisation to all new staff,
although many staff were not fully protected
when they first commenced clinical duties. The
main finding of this study is the gap between staff
perception of working to infection control policies,
procedures and work instructions and the docu-
mented availability of these papers. Many surger-
ies had access to, and used, the BDA Advice
Sheet A12 which, although providing broad
principles, is insufficiently detailed to provide pro-
cedures and work instructions for many aspects of
infection control and decontamination of instru-
ments. This is highlighted by the lack of knowledge
of the dental team on interpretation of the ‘single
use’ symbol on medical device packaging. The de-
ficiencies in the management of infection control
were also highlighted by the lack of specific infec-
tion control meetings, document control and audit
of infection control practices. This probably
reflects the lack of training and education in the
application of quality management systems and
the small number of staff in a dental surgery.
In regard to hand hygiene, it is apparent that
the profile of this basic measure was not as high as
it might have been and, if in place, was outdated.8
Just over half of staff incorporating hand washing
into their training and the majority of surgeries
used surgical hand scrub for routine hand washing.
In relation to waste disposal, the majority of
practitioners were undertaking appropriate segre-
gation and disposal of clinical waste. The range of
methods for disposal of partly discharged anaes-
thetic cartridges and extracted teeth reflects the
lack of clear guidance and changing legislation in
this area; it is not appropriate to dispose of used
cartridges in yellow plastic sacks.
The study has shown that there is no traceabil-
ity of decontaminated instruments through the
cleaning or sterilisation process. In the event of
an adverse incident these records would do much
to protect the practitioner and limit subsequent
investigations. The use of batch-related records
for instrument decontamination as part of a quality
management system would be a sufficient reassur-
ance since it seems unlikely that a fully traceable
system linking individual instruments to patients is
viable at the present time for dental practice.
Many practices lack a properly managed
infection control system. The risks clearly identi-
fied in this study could be rectified by the appli-
cation of an appropriate quality management
system.28e30 Local decontamination units do not
require a system as extensive as that applied in
central decontamination units but should have
documented policies, procedures and records for
all the key elements of the decontamination
357
process.9,31,32 Such a quality management system
should also be applicable to other aspects of den-
tal practice and not specifically implemented just
for infection control. However, it is essential that
whichever quality system is adopted it should
consider the relatively small numbers of staff
involved and ensure that generation of documen-
tation is not an end in itself but should be
a value-added activity. Dental practices should
also give consideration to adoption of a hazard
analysis and critical control point (HACCP) type ap-
proach.10,11 This system has been adapted for use
in other small professional and industrial environ-
ments, such as food premises, together with a sys-
tem of independent inspection. Application of the
HACCP system is also compatible with the imple-
mentation of total quality management systems,
such as the ISO 9000 series.
In conclusion, the deficiencies identified in this
study can be rectified by changes in core training
at undergraduate level and within the continuing
professional development of both dentists and
dental care professionals. Expert guidance is
needed to institute the introduction of an appro-
priate quality management system in dental
practice if long-term investments and improve-
ments in risk reduction are to be maximised.
Conflict of interest statement
None declared.
Funding sources
Study supported by a grant from the Scottish
Executive Health Department.
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