Professionalism and the Foundations of Dental Practice

Professionalism is one of the most important fundamental aspects for a healthcare practitioner. It embodies the very essence of how a private practice should be operated properly. This is because it encompasses not one particular aspect of a practice, but all aspects. Without it, not only would the practice ultimately fail, but also everyone associated with the practice (patients, doctor, and staff) may be affected in such a way that his or her very well being, health, and safety may be put at risk. Professionalism does not strictly apply to private practice though. Professionalism applies to other healthcare facilities including educational institutions like Nova Southeastern University.

One of the fundamental aspects of professionalism in the dental practice is infection control. The same protocols apply to the orthodontic practice as well. This is because dental patients and dental healthcare providers have the potential for exposure to a vast array of microorganisms including HBV, HCV, HIV, CMV, HSV1, HSV2, Mycobacterium tuberculosis, staphylocci, streptococci and others.

Infection control is broken down into two tiers of recommended precautions within the healthcare setting: transmission-based and standard precautions. The less common transmission-based precautions are added level of precautions to standard precautions that are used when patients may be infected or colonized with certain infectious agents. These precautions are more often used in a hospital-based setting with added precautions like ensuring the patient is placed in an airborne infection isolation room (AIIR) in the case the patient is known or suspected to be infected with Tuberculosis and limiting transport and movement of the patient outside of the room for solely purposes that warrant medical necessities.

The more common tier of infection control within an orthodontic practice is standard precautions. These are used on every patient. Standard precautions are divided into sub-categories that include: hand hygiene, use of personal protective equipment (PPE), respiratory hygiene/cough recommendations, proper patient placement, proper handling of clean and disinfected instruments, handling of laundry, injection safety, and proper handling of sharps.

The recommended protocol for hand hygiene will vary depending on the procedure done, the amount of contamination present, and the desired persistence of antimicrobial action on the skin. Hand washing with soap and water is indicated when there is visual evidence of contamination of the hands with proteinaceous material or when they are visibly soiled with body fluids like blood. If the hands are not visibly soiled, then an alcohol-based hand disinfectant is suitable to decontaminate the hands. It is important for the healthcare provider to understand that gloves do not preclude the need for hand washing. The hands must be decontaminated before direct patient contact. Kalra et al. recommend hand washing for one minute under cold water to minimize the amount of skin pores that open and then use a hand disinfectant afterwards. To minimize dryness that may occur as a result of frequent hand hygiene, a lotion may be used. However, petroleum-based lotions should be used only at the end of the workday to minimize any latex glove weakening and increased permeability.

Personal protective equipment (PPE) in the dental setting involves certain protective clothing like gowns, gloves, masks, protective eyewear, and face shields. PPE is aimed to protect against exposure of the mucous membranes of the eyes, nose, and mouth and the skin to blood or other potentially infectious materials (OPIM). This is especially important when using rotary dental instruments like handpieces that create a visible spray (composed of aerosols and spatter) that may contain potentially infectious agents.6 Honda and Iwata recommend that to improve proper PPE compliance, the most important approach is through training and education. Specifically, healthcare workers should receive repetitive hands-on training periodically to reinforce the principals that govern proper PPE compliance. To preclude contamination of normal, everyday clothing, protective clothing should be worn. The protective clothing should be changed as quickly as possible when the healthcare provider notices visible contamination of it. Before leaving work, the healthcare provider should also remove all protective clothing and equipment. OSHA states that employers are responsible for training employees on proper PPE protocols, for providing the PPE, and ensuring that the work place is best equipped to minimize potential health and barrier hazards by doing a hazard assessment. For an employer to select the PPE that is best suited for employee protection, OSHA requires that much of the PPE including eye and face protection to meet the stands set fort by the American National Standards Institute (ANSI). However, this is no ANSI standard for gloves, therefore, OSHA recommends picking gloves that are best suited for what tasks are to be done. A meta analysis by Brewer et al. compared the rates of surgical site infection (SSI) between sterile and non-sterile gloves in common outpatient dental procedures and found no difference in the rate of postoperative SSI between the two gloves.

The sterilization of equipment and dental instruments falls into three categorizes: critical, semicritical, and noncritical. These categories are based on the item's potential risk to transmit infectious agents associated with its intended task. Critical items represent the highest risk of disease transmission. As such, they should always be heat sterilized. These items include instruments use to penetrate the soft tissue and bone like surgical instruments and periodontal scalars. For orthodontic practices, these items include temporary anchorage devices (mini-implant placement kits), bands, band forming pliers, band removers, and ligature directors.

Semicritical items have lower risks than critical items for the transmission of diseases. They include items that come into contact with non-intact skin and mucous membranes like amalgam condensers, dental impressions tray that are reusable, mouth mirrors, and retractors. As such, the majority of these items are heat tolerable and should be heat sterilized when they are. If they cannot be heat sterilized, the item should either be replaced with a heat tolerant one or a disposable alternative found that is used only once and discarded appropriately. Most orthodontic instruments also fall under this category. A very important item that also falls under this category is the dental handpiece and its associated attachments including reusable prophy angles and low-speed motors. These items should never be disinfected with a surface or high-level disinfectant and instead, always heat sterilized between patients.10 This is because studies have shown that during patient use, the internal structures of the handpiece and its associated attachment can become contaminated which puts the next patient at risk to potentially infectious materials if only disinfected and not heat-sterilized.10 In fact, a 2017 study aimed at evaluating the level of disinfection of high-speed handpieces with 70% w/v alcohol found the that level of bactericide and fungicide action was insufficient with the survival of microorganisms and spores that normally would be killed with heat-sterilization.11 In 2018, the CDC updated their recommendations for dental handpieces and recommends that if a handpiece or intraoral device can be removed from dental unit air and waterlines, then they should be cleaned and heat-sterilized between patients. To best follow proper protocols, the CDC recommends that DHCPs follow the manufacturer's instructions for sterilizing, cleaning and lubrications the devices. In addition, the handpieces should have FDA clearance. In the even that the handpiece does not have FDA clearance and cannot be heat-sterilized, it should be discarded immediately.12 For other orthodontic instruments, chemical disinfection is more detrimental to the lifespan of these instruments like cutters than is autoclave sterilization. Chemical disinfection may cause unwanted, localized corroding like pitting which is more deleterious for the patient than surface corrosion. The same can be sad for surface disinfectants that come in the form of a spray, because the pH within the spray may damage the chromium oxide layer of the instrument.

Finally, noncritical items include those items that pose the least risk of transmitting infectious materials by contacting skin that is still intact and thus is an effective barrier to microorganism penetration. They include items like blood pressure cuffs, facebow, pulse oximeter, and radiograph head/cone.10 In the case of orthodontic equipment, Kalra et al. identified least critical objects that those instruments that do not touch the mucous membranes. They include orthodontic instruments like ligature cutters, torquing keys, distal-end cutters, V-bend forming pliers, arch form pliers, and bracket positioning gauges. All of which must be disinfected.5 Unless visibly soiled, cleaning is sufficient. If visibly soiled, then an EPA-registered hospital disinfectant should be used after cleaning. When the item is visibly soiled with OPIM or blood, then an intermediate-level disinfectant should be used with tuberculocidal claim. Depending on the intended use of the item within the dental practice, that should determine the level of disinfection necessary and as such DHCPs should closely follow the manufacturer's directions regarding exposure time and concentrations for proper disinfectant activity for that specific product.

When sterilizing instruments, it's crucial to adhere to standard protocols to ensure that the sterilization process is effective. Before sterilizing and disinfecting instruments, it is vital to remove debris and organic contamination from blood and saliva. Failure to do so may result in microorganisms being protected underneath the debris and compromise the sterilization efficacy. This can be done using an ultrasonic cleaner or washer-disinfector.The instruments should be dried after cleaning and inspected, wrapped, and packaged before heat sterilization. Sterilizer performance is critical and as such must be monitored regularly to ensure its performance is working properly. Using a combination of indicators that are biological, chemical, and mechanical in nature can do this. The most accepted method to do for monitoring sterilization is using biological indicator, otherwise known as spore tests. This is because the spore tests use highly resistant microorganisms like Geobacillus or Bacillus species and directly assess the killing process. Spore tests must be done once per week at a minimum. Because spore tests are only done sporadically, mechanical and chemical tests should also be used. While they do not guarantee sterilization, they allow the DHCP to assess any procedural or equipment errors and malfunctions that may be occurring. Mechanical monitoring involves assessing sterilization equipment by looking at computer printouts, gauges, exposure times, temperature readings, etc. Chemical monitoring involves assess color changes that occur in certain chemical when exposed to high temperatures. Examples of these chemical indicators include strips or tabs and chemical indicator tapes. Inside every package, there should be a chemical indicator so that the DHCP can see that the sterilization process made it inside the package. An external indicator should be also be used in cases where the DDHCP cannot see the internal chemical indicator. If there is no change in color of the chemical, those dental instruments should not be used. Finally, it's vital to maintain accurate records to ensure that the sterilization is being done properly and effectively to establish accountability. To achieve this, it's important to have the manufacturer instructions readily available for use. It is also important to assign responsibilities for reprocessing of dental equipment to employees who are appropriately trained in sterilization duties. During the handling and reprocessing of instruments, and equipment, DHCP should always wear PPE.

Environmental surfaces should also be routinely cleaned and disinfected. Before disinfection, cleaning should always be done as it removes a large proportion of microorganisms prior to disinfection. Disinfection kills all microorganisms that are recognized as being pathogenic except for bacterial spores. In fact; Rutala et al. defined sterilization as killing of all microorganisms including bacterial spores. Examples include steam at high temperatures and liquid immersion with chemical sterilants. Disinfection was categorized into high and low-level disinfection. High-level disinfection involves destroying all microorganisms except for high numbers of bacterial spores. Examples include pasteurization and liquid immersion with a different chemical sterilant. Low-level disinfection does not destroy bacterial spores as well as mycobacteria. It does destroy vegetative bacteria and some fungi and viruses. Examples include EPA-registered disinfectants that have no tuberculocidal claim and 70-90% alcohol.

Cleaning and disinfecting should be emphasized on environmental surfaces where there is a high chance for contamination with pathogens. Examples include clinical contact surfaces like bracket trays, light handles, switches for dental units, and computer keyboards. To minimize the level of contamination whenever possible, the DHCP should place a protective barrier over the surfaces. After, the surfaces should be cleaned and disinfected between patient.10 Housekeeping surfaces that pose less of a risk of being contaminated can be cleaned with regular soap and water unless there is visible evidence of contamination with blood, then they too, must be disinfected.10

Bacterial growth and biofilm formation are also very prevalent in dental unit waterlines. Their formation occurs because of uneven water flow rates, the long narrow-bore tubing present within the waterline, and because oral fluids may be retracted within the system. The water must be treated to meet the standards consistent with typical drinking water set for by the EPA of less than or equal to 500 CFU/mL of heterotrophic bacteria. Simply providing water-bottle systems or using independent reservoirs is not enough to ensure quality water standards. Cleaning dental unit waterlines can be difficult. Szymanska and Sitkowska found that contamination of waterlines occurred regularly with aerobic and facultative anaerobic bacteria. Mesophile bacteria had mean concentrations that exceeded 1.1x105 CFU/mL in the dental unit reservoir. Bulkholderiaceae, Rolstoniaeceae, Sphingomonadaceae, and Pseudomonadaceae were the predominant Gram-negative bacterial species found within the dental unit reservoir. Nearly half of all aerobic and facultative anaerobic bacteria constituted Ralstonia pickettii. Brevibacterium were the highest percentage among Gram-possible rods while Actinomyces species had the highest percentage shares of all Gram-positive microorganisms. Given the diversity of microorganisms within the dental unit waterline, the ADA recommends testing the water that comes out of the unit. There are produces that can estimate the number of free-floating heterotrophic bacteria within the unit. There are also water quality indicators that cannot only detect the type of aerobic mesophilic heterotrophic waterborne bacteria but also the concentration too. There are four methods to improve the water quality within the dental unit. None of the methods will eliminate biofilms though. The four methods include: chemical treatments, filtration, anti-retraction valves, and using water sources that are separate from the public water system. The best way to maintain the dental unit waterlines and ensure high water quality is to follow the manufacturer's recommendations for monitoring water quality and invoke strict protocols with staff involving regular water checks. A study by Wirthlin and Roth found that chlorine dioxide waterline cleaners were the most effective at containing dental-unit waterline contamination.

In cases of accidental exposures, immediately wash cuts and needlesticks with soap and water. Eyes should be irrigated with water or saline solution. Flush splashes should be performed to the nose, skin, and mouth.18 In the cases of potential bloodborne exposure to HIV, immediate medical consult should be done. Postexposure prophylaxis (PEP) will often be initiated that involves a combination of three or more antiretroviral drugs for a four-week duration. Close follow-up and counseling will also be done from baseline to six months after exposure. Adhering to strict infection control practices within orthodontic practices and educational institutions as a whole is vital to patient and DHCP safety. It does not matter if it is here at Nova Southeastern University or in private practice. The use of standard precautions helps mitigate the risks of contamination to microbial pathogens and exposure to infectious materials. The onus is on the orthodontist and other DHCPs to ensure that infection control procedures are never deviated from the standard, that infection control is always made a priority, and that routine education is given to keep up-to-date with the latest guidelines. Maintaining a sense of professionalism and integrity will ensure that such principles and protocols are followed. As one of the key components of ethics, integrity ensures that the DHCP maintains a strong sense of moral character and subsequently leads by example. Only then can the DHCP achieve a level of respect, honor, trustworthiness, dependability, honesty, and truthfulness.

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