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In 1986, there was growing concern about infectious disease transmission in dental healthcare settings due to the human immunodeficiency virus (HIV) pandemic. In response, the Centers for Disease Control and Prevention (CDC) issued the first infection prevention and control (IPC) guidance for dentistry.1 Those recommendations were followed with updated CDC guidelines for infection control in dental settings in 1993 and again in 2003.2,3 These guidelines focused, respectively, on universal precautions and standard precautions to prevent the transmission of diseases through direct or indirect contact with patients' body fluids. While universal precautions focused on treating body fluids as if capable of transmitting bloodborne diseases such as hepatitis B, hepatitis C, and HIV, standard precautions expanded the parameters to include all body fluids, excretions, and secretions, with the exception of sweat. These guidelines formed the basis for infection control programs in dental care settings. The Occupational Safety and Health Administration (OSHA) also issued regulatory standards for bloodborne pathogens in healthcare settings in 1991.4 However, these regulations only apply to diseases that can be transmitted via the blood of infected patients and, therefore, are not adequate to prevent all potential infectious disease transmission.
The emergence of SARS-CoV-2 in 2020 presented new challenges in IPC for dental healthcare personnel (DHCP). A question that many such personnel may be asking currently is whether IPC in dental settings has changed forever because of information that has been learned during the protracted COVID-19 pandemic. The response may require that the traditional view of IPC in dental settings be broadened to understand how already-established IPC guidelines and practices may be applied to the oral healthcare setting.
Interim IPC Guidelines During COVID
Soon after the SARS-CoV-2 pandemic was declared by the World Health Organization on March 11, 2020, the CDC began providing guidance on IPC practices for DHCP that went beyond standard precautions. The CDC Division of Oral Health issued and then updated guidelines several times for prevention of COVID-19 in dental healthcare settings. In February 2022, the CDC removed the dental-specific interim guidelines in favor of recommendations that encompass all healthcare settings.5 The broader interim guidelines address the need to expand standard precautions to include some elements of transmission-based precautions.6,7 Within the interim guidelines, specific guidance for DHCP is included, such as precautions for aerosol-generating procedures (AGPs).
Transmission-based precautions are used in the care of patients who may be infected with certain infectious diseases for which standard precautions may not be adequate.7 This second tier of basic infection control precautions applies to pathogens that may transmit primarily via contact, droplet, and airborne routes. Elements of transmission-based precautions include practices such as having patients wear face masks, patient placement away from other patients, use of protective masks (such as N95 models) for healthcare personnel, use of gowns and gloves in all interactions with patients, use of airborne infection isolation rooms, and modified personal protective equipment (PPE) donning and doffing sequences, among others (Table 1). Many of the elements of transmission-based precautions cannot be reasonably implemented in most dental settings. Therefore, treatment needs to be delayed for most patients requiring isolation precautions until their infection has resolved.
The precautions recommended to prevent the transmission of COVID-19 in healthcare settings employ a tiered approach, where the level of precautions or the specific type of IPC measure recommended depends on the level of community transmission of COVID-19.4 Community transmission is calculated by the CDC and provided in an online tool that allows individuals to check the transmission levels in their area.8 The CDC data tracker follows both community levels and community transmission rates for COVID-19. For the purposes of determining which IPC recommendations are appropriate, DHCP should use community transmission rates.5 These guidelines will remain effective until the CDC determines that specific COVID-19-related IPC recommendations are no longer necessary and removes them in favor of returning to or updating pre-pandemic guidelines.
CDC Core Practices
Moving forward from the interim guidance in effect during the COVID-19 pandemic, it would be useful for DHCP to be familiar with the core practices for IPC as the foundation for IPC policies and practices. The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee that provides advice and guidance to the CDC regarding infection control. In 2014, the CDC published Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings-Recommendations of the Healthcare Infection Control Practices Advisory Committee, which was updated in 2017.9 The core practices are those elements that are widely agreed upon as accepted practices that are not anticipated to change and are strongly recommended by the CDC.9 These core practices apply to all settings where healthcare is delivered, including oral healthcare settings. Additional CDC guidelines provide background and rationale for these core practices. Some examples of additional guidelines include Guideline for Isolation Precautions (transmission-based precautions), Guidelines for Environmental Infection Control in Health-Care Facilities, Guideline for Disinfection and Sterilization in Healthcare Facilities, and Guideline for Hand Hygiene in Health-Care Settings, among others.7,10-12 The core practices synthesize and summarize key elements of those comprehensive guidelines.
The core practices are divided into 14 specific categories (Table 2).9 Each category includes an explanation of the core practices themselves and a section that contains comments that provide rationale, further explanation, or references to other CDC guidelines. The core practices address programmatic needs as well as precautions. Notable among the programmatic needs is the emphasis on leadership support, including the allocation of sufficient resources, both human and material, to ensure consistent and prompt action to mitigate infection risks. Depending on the size of the facility or organization, one or more qualified and appropriately trained person should be assigned to manage the infection prevention program; this person is, in essence, an infection control coordinator.
All DHCP should receive education and training to ensure they understand and are competent in the IPC practices necessary for them to perform their responsibilities. Systematic monitoring of some IPC practices to ensure a safe environment for patient care may often be lacking in oral healthcare settings.13-15 Regular monitoring, review of results, and feedback should reveal trends where some precautions are more routinely followed than others. Such monitoring provides the dental team with information upon which to determine where intervention should be implemented to produce improvement. Continuing the monitoring cycle will help team members understand if the interventions were effective because compliance should improve after a deficiency is identified and addressed.
One tool available to monitor IPC is the CDC Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.16 The CDC Division of Oral Health developed the summary guide to assist DHCP in understanding the infection control recommendations for oral healthcare settings. The document includes a comprehensive checklist that can be used to systematically monitor compliance with the CDC guidelines.
The remaining core practices focus on steps to prevent the transmission of infectious diseases in healthcare settings. These include standard precautions, hand hygiene, cleaning and disinfection, injection safety, PPE usage, exposure prevention, reprocessing of reusable instruments and equipment, transmission-based precautions, and occupational health.
Protocols for Dentistry
• Some examples of core practices for IPC that dental practices should incorporate include:
• ensuring DHCP have received their recommended vaccinations, including the annual influenza vaccine
• establishing standard operating procedures for instrument processing that include transporting, cleaning, packaging, sterilization, and storage of reusable heat-resistant instruments and devices that contact patients' oral fluids or mucous membranes
• maintaining sterility assurance, including the monitoring of cycle times and pressure, chemical indicators, and biologic indicators (spore tests) at regular intervals in keeping with CDC guidelines and any state regulations
• using safety devices and safe handling practices (eg, needle recappers, scoop recapping, safety scalpels) to prevent percutaneous exposure to patient blood and body fluids
• having a protocol in place for swift follow-up of any exposure incidents, including referral to a healthcare provider for testing and evaluation regarding the need for post-exposure prophylaxis
• selecting PPE based on the nature and degree of exposure (eg, procedures that produce spray or spatter of patient blood or saliva)
• following the directions for use by the disinfectant manufacturer for cleaning and disinfecting clinical contact surfaces
• in dental clinics where intravenous or intramuscular medications are administered, using single-dose vials and designating a separate space for drawing up medications
Conclusion
The COVID-19 pandemic has demonstrated to the oral healthcare profession that a single set of IPC precautions, such as standard precautions, may not be adequate for all situations and all patients. Becoming familiar with the core practices discussed in this article, and critically evaluating each facility's ability to manage IPC beyond standard precautions, should help DHCP ensure a safe environment in which to work and for patients to receive care. The first step is to identify the limitations of each setting in the context of transmission-based precautions and limit care to that which can be safely carried out. Screening patients for droplet- and airborne-transmissible diseases and implementing recommended transmission-based precautions where appropriate should be routinely practiced. Where it is not possible to implement appropriate controls for a given patient's condition, DHCP should delay care of that patient until the patient is no longer infectious.
If emergency care is necessary for patients with active respiratory infection believed to be transmitted via droplets, care should be limited to that which can be safely performed, such as avoidance of AGPs in the presence of an infection transmitted via the droplet route.. Additional controls in such a situation could include placing the patient in a room separated from other patients and personnel and having the patient wear a mask when not actively receiving treatment. It is recommended that patients who are infected with an airborne-transmissible disease, such as active tuberculosis, measles, or chicken pox, not be treated in a typical office setting during their infectious period. If treatment of these patients cannot be delayed or treatment with pain medications and antibiotics is not an option, referral to a facility equipped to provide treatment to patients with active airborne infections may be necessary.
As part of the healthcare profession, DHCP are in an ideal position to ensure oral healthcare is included in the larger patient safety movement, of which IPC is a major part.
About the Author
Eve Cuny, MS
Executive Associate Dean and Professor, University of the Pacific Arthur A. Dugoni School of Dentistry, San Francisco, California
Queries to the author regarding this course may be submitted to authorqueries@broadcastmed.com.
References
1. Centers for Disease Control (CDC). Recommended infection-control practices for dentistry. MMWR Morb Mortal Wkly Rep. 1986;35(15);237-242.
2. Recommended infection-control practices for dentistry, 1993. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1993;42(RR-8):1-12.
3. Kohn WG, Collins AS, Cleveland JL, et al, and Centers for Disease Control and Prevention (CDC). Guidelines for infection control in dental health-care settings-2003. MMWR Recomm Rep. 2003;52(RR-17):1-61.
4. 29 CFR Part 1910.1030, occupational exposure to bloodborne pathogens-OSHA. Final rule. Fed Regist. 1991;56(235):64004-182.
5. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. CDC website. February 2, 2022. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed November 4, 2022.
6. Centers for Disease Control and Prevention. Transmission-based precautions. CDC website. January 7, 2016. https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html. Accessed November 4, 2022.
7. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; Updated May 2022.
8. Centers for Disease Control and Prevention. COVID data tracker. COVID-19 integrated county view. CDC website. https://covid.cdc.gov/covid-data-
tracker/#county-view?list_select_state=all_states&list_select_county=all_counties&data-type=Risk&null=Risk. Accessed November 4, 2022.
9. Healthcare Infection Control Practices Advisory Committee. Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings - Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC). CDC website. Updated March 15, 2017. https://www.cdc.gov/hicpac/pdf/core-practices.pdf. Accessed November 4, 2022.
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