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Thu 16 Oct 2008 04:00 AM

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Building barriers

Are dentists making the grade on infection-control policies?

Are dentists making the grade on infection-control policies?

A recent poll on infection control published in the Journal of the American Dental Association raised eyebrows for the wrong reasons. The survey of 352 New York dentists revealed almost a quarter didn't wear gloves, while 19% admitted to not washing or disinfecting their hands between patients.

The results, while startling, tap into a dirty truth about dentistry; infection-control procedures are rarely seen as a positive addition to daily practice.

Although there's little data on infection-control practices in the Middle East, anecdotal evidence suggests dentists find it similarly tedious in terms of time and money. But, as regional cases of avian flu and drug-resistant tuberculosis show, dentists can't afford to let standards lapse.

MED asks: is the dental community doing enough to keep infection control at the top of its agenda?

Law and enforcement

Dr Iyad Hijjawi is the general manager of the Middle East Centre for Infection Control Technologies. With a few exceptions, he notes, the region has strong infection control laws. But these are undermined by poor enforcement.

"Most government authorities in the region adhere to the American Centres for Disease Control and Prevention guidelines," reveals the Jordan-based dentist. "They are usually pretty stringent. But there are inconsistencies in the policing of infection control."

Regulation is tighter for dental surgeries located in hospitals, polyclinics and large primary care centres, Hijjawi claims. But many governments, including those in Jordan and Syria, struggle to find the manpower to police their bustling private dental sectors.

"There are often thousands of dentists in solo practice, spread over a wide area, and providing varying degrees of infection control.

"Because of the widespread nature of the dentists in these countries, it becomes very expensive and logistically difficult for the health authorities to carry out regular inspections and enforcement of infection-control policies."

While a certain amount of responsibility for enforcing controls lies on the shoulders of government departments, the dental industry has always prided itself on being largely self-regulated. So what leads dentists to flout policy and risk patient safety?

According to Dr Wassim Slim, dentist at the British Dental Clinic in Dubai, the overriding reason is time. "I have worked in dental surgeries before where it is the dentist's nurse that is expected to clean all of the instruments. So she is rushing to get everything ready before the next patient," he says. "Invariably, there will be times when things will get missed."

For single-dentist clinics, the pressure is even greater.

"It's very easy to let things slip and take shortcuts when you are under pressure," Hijjawi agrees. "Probably the biggest faux-pas that a dentist can make is to not sterilise instruments in between patients."

The cost conundrum

The second major cause behind lax cross infection control is cost.

The estimated cost to clinics maintaining a watertight infection control policy can be upwards of US$25,000 per year. This roughly equates to between $5 and $20 per patient per procedure, depending on the treatment. Topping the price list are disposable instruments and tools, consumables such as gloves and clinical waste removal, among others.

Infection control is also equipment-based, meaning the costs increase year-on-year. Adding to this, admits Hijjawi, is the general push by local health authorities towards more international standards.

"The cost of infection control is forever spiralling. Two things push the costs up - increased regulations and increased standards. Because we now have to dispose of so many things, the percentage of our turnover each month that is spent of infection control has gone up significantly."

For dentists struggling to meet overheads, this can be the tipping point, claims Hijjawi.

"Dentists are notoriously bad businessmen and they are always looking to make savings. Unfortunately these tend to be in the wrong places. That is just a fact of dental business.

"It is sadly quite a common practice for items that are meant to be disposed of after first use, to be reused again to save money."

Start-up practices are among the worst offenders. The massive investment required to fund the business means there is not always enough left in the pot for disposables. "Often, certain instruments have to be bought second-hand," Slim says.

With the use of more disposable tools and instruments comes another problem that can impact good practice. The Middle East is notorious for its difficulties in maintaining a stable supply of dental equipment. It is not uncommon for dentists to have several different suppliers for the same disposable instruments and materials.

"It is an absolute nightmare," laments Slim. "Suppliers are always running out; shipments from America and Europe are sporadic and unreliable and you do not always get the same things."This, he adds, can lead to the repeated use of single-use tools out of necessity.

"You almost have to just get what is on offer and take what you are given. It's not unheard of to have to wait up to five months to get a specific item." Educate to eradicate

It's widely acknowledged that any concerted efforts to raise infection control standards need to start in the classroom. Currently, regional dental schools devote a minimal amount of time to barrier policies; a decision that Dr Hijaawi feels undermines the importance of good practice.

"It comes down to education at the end of the day," he explains. "There needs to be a greater emphasis on cross-contamination in the graduate dental curriculum.

"At the moment the issue is an aside, it is a small part of the wider course. However, I would rather see cross-infection control added to the syllabus as a separate module."

He is not alone in thinking that graduating dentists should have a greater awareness of infection control's importance in the practice.

"I believe it should be more formalised. There should be lectures and seminars in the subject and there should have an exam in it - it should be assessed," says Slim.

"If anything, students should probably learn in detail about proper cross-infection controls before they even touch their first patient. It should not be something that is just picked-up in the clinic through general work."

Hijjawi is also an advocate of short continuing education courses for practising dentists. "It is important that there are opportunities for dentists to familiarise themselves with the latest techniques and technologies on a regular basis. In my opinion, there are not enough of these courses in the region."

Equally, Slim suggests that not enough funding goes into training the region's dental nurses and assistants. "I think a lot of dentists look at the assistant as just a necessary burden; as someone they have to pay to be there while they work.

"Inevitably, they just want to get them into the surgery and get them working as quickly as possible since it is costing them money. So they are not inclined to spend two or three days training them.

"The entire set-up at the end of the day is the responsibility of the dentist. It is not an adequate excuse for the nurse or assistant to say ‘I didn't know that I had to do that'."

Prevention pays

As well as the obvious safety rewards, there is a soft benefit to having an airtight infection control procedure. According to Slim, patients are usually willing to pay a little extra for the piece of mind. He says that a clinic's cleanliness can be a marketing tool.

"Infection control is not cheap and these costs are ultimately passed on to the client. It is called dental inflation," he explains. "Patients do pay more, but they do so knowing that they are getting very hygienic care, so it does pay for itself in the end.

MED TIPS: How to achieve infection perfectionTrain, retrain and completely immunise staff.

Have an infection control manual and ensure that staff abide by it.

Wash hands and change gloves between every patient.

Sterilise all instruments, and disinfect anything that cannot be put in the autoclave.

Flush waterlines at the beginning of each session and between patients.

Reduce contaminated aerosol by using high volume suction, antimicrobial mouthwash, purified water, good surgery ventilation and air filtration.

Always wear personal protective equipment such as goggles and masks (this applies to both patients and clinical staff).

Handle and dispose of sharps properly.

Always use disposable barrier shields on equipment.

Regularly review and quality assure the practice's infection-control policy.

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