Guidelines, of course, are necessary for preventing disease transmission and managing health concerns in dentistry; however, equally important is DHCP’s extent of compliance with them. Many surveys have assessed infection control practices in dentistry.^11–18 Some have examined infection control in general,^13,14,17,19 while others have concentrated on one particular aspect.^20,21 Studies that have assessed compliance with procedure recommendations and guidelines have done so over time,¹¹ among different specialties^22–24 or as a function of specific demographics.²⁵ While all of these surveys have yielded useful information, little work has been done to assess infection control as practiced in government dental clinics.²⁶ There is, in particular, a paucity of information concerning infection control procedures in military dental facilities and the degree to which clinic personnel comply with existing guidelines.²⁷ Having specific information about the current practice of infection control is vital if compliance is to be assessed accurately and appropriate levels of training developed. This is particularly important for the military because, in addition to following national infection control guidelines, some government departments and military services have established additional guidelines that may be more stringent than national ones. It is vital, therefore, to know if DHCP are complying with these department- or branch-specific guidelines.

Having specific information about the current practice of infection control is vital if compliance is to be assessed accurately and appropriate levels of training developed.

The purpose of our research was to assess characteristics of infection control programs and current infection control practices in U.S. Air Force (USAF) dental clinics for the purpose of updating previously issued guidelines and developing infection control training programs.

	MATERIALS AND METHODS

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In August 2003, we mailed a 60-item self-administered survey to the commanders of all USAF dental clinics located in the United States and overseas (n = 82). The survey instrument consisted primarily of fixed-response questions with a small number of open-ended items. The survey assessed the following aspects of the clinics’ current infection control programs:

– management and training;

– use of prevention practices (such as personal protective equipment [PPE), managing occupational exposure incidents, work practice and engineering controls);

– sterilization procedures;

– disinfection practices;

– dental unit water quality practices;

– surveillance methods (such as sterilizer monitoring, waterline monitoring and health care–associated infection surveillance).

We mailed surveys with a cover letter explaining the issue of anonymity, the purpose of the survey and instructions for completing and returning it. The principal investigator (J.A.H.) compiled the survey results, and we used a statistical software package (SAS Version 8.02, SAS Institute, Cary, N.C.) to obtain descriptive statistics of the data. If a particular question was not answered on a survey form, we calculated the reported ratio for that question on the basis of the actual number of responses to it rather than on the total number of surveys.

	RESULTS

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We received completed surveys from all dental clinics, for a response rate of 100 percent. For clarity of reporting, we present the various assessed aspects of the clinics’ infection control programs separately below.

Program management and training. All dental clinics (100 percent) reported having both an officer and an enlisted person assigned to manage their infection control programs (Table 1). In the military, these people are the equivalent of civilian infection control coordinators. Only a minority of these assigned USAF people (officers, 35.4 percent; enlisted personnel, 18.3 percent) had received formal infection control training by attending the annual Federal Services Dental Infection Control and Occupational Health Course sponsored by the Federal Dental Services and the Organization for Safety and Asepsis Procedures. Clinics reported having copies of previously published infection control guidelines and/or recommendations available for reference.

Preprocedural use of mouthrinses also showed some disparity between facilities. A majority (70.7 percent) used them and, in those clinics, the most commonly used mouthrinse was a commercial, over-the-counter product.

Instrument-processing practices. A high percentage of USAF clinics (98.9 percent) had a centralized dental instrument processing center (DIPC), where instruments are cleaned and prepared before heat sterilization. All the clinics organized their work space to create separate areas for cleaning instruments and packaging them. For cleaning instruments, many clinics used tabletop ultrasonic cleaners (46.3 percent). In addition to tabletop ultrasonic cleaners, almost all clinics had either an instrument washer or thermal disinfector (95.1 percent). Most facilities (86.6 percent) used event-related packaging documentation; only 6.1 percent used date-related packaging. For sterilization, all of the clinics reported using either steam or dry heat sterilizers; none used unsaturated chemical vapor sterilizers. All clinics reported sterilizing their handpieces.

Evaluation and surveillance. Dental unit water quality. All clinics reported taking measures to improve dental unit water quality. In addition to using sodium hypochlorite to treat dental unit waterlines (DUWLs), the dental clinics reported using a variety of commercially available chemical treatment products. Clinics used both continuous and periodic treatment protocols.

Inspection and monitoring. To assess compliance with current standards, all 82 clinics held periodic inspections, with most being performed weekly (58.5 percent) or monthly (19.5 percent). A smaller percentage (17.1 percent) conducted them twice monthly, and only 4.9 percent did so quarterly. To monitor the effectiveness of their steam sterilizers, 100 percent of the clinics used biological indicators (that is, spore tests) in addition to chemical and mechanical indicators. Nearly all of the clinics (95.1 percent) monitored DUWLs, with most using a commercial product for in-office testing (76.2 percent). The remaining clinics that monitored water quality sent their test samples to an on-site laboratory for analysis (18.8 percent). A large majority of clinics (92.6 percent) had an established surveillance program in place to monitor and report health care–associated infections (Table 4).

	DISCUSSION

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It is important to note that this survey was conducted before the release of the CDC’s most recent and comprehensive publication on dental infection control, Guidelines for Infection Control in the Dental Health-Care Setting—2003. Although the majority of its recommendations should be familiar to most dentists and probably already are being practiced, the guidelines add a number of new recommendations and consolidate previous recommendations. In addition, it discusses new issues and concerns not addressed previously.¹⁰ Changes have been implemented in Air Force dental clinics as a result of this new information, and a follow-up survey is planned for late 2005 to assess the progress and success of the changes.

Our survey relied on self-reporting, as have previous studies. Although prior studies have asked similar questions, most have done so in a different manner or have surveyed different populations (for example, dentists, dental assistants, dental hygienists) and/or different regions of the United States and Canada.^11–26 As always, there is room for interpretation of some questions. Also, a comparison of our findings with those of previous studies can be problematic, because infection control practices have evolved with time and few studies have been conducted in the last several years. With these limitations in mind, some comparisons can be made.

Education and training. Infection control education and training, both initial and recurrent, is key to the success of an infection control program. While neither the 1993 CDC nor 1996 American Dental Association (ADA) infection control recommendations made a formal recommendation to have an infection control coordinator, USAF guidelines require oversight of the dental clinic infection control program by either an officer or an enlisted person. Our results indicated that all clinics had both an officer and an enlisted person assigned to this position. By comparison, a survey of civilian dental hygienists in 1996 reported that only 10 percent of practices had an infection control coordinator.¹⁴

The USAF strongly encourages appropriate education and training of people before they assume these duties. The USAF has offered an annual, multiple-day dental infection control and safety course since 1994. While 72 percent of the clinics reported having at least one staff member who had attended the course, only a minority of the assigned program managers had attended. Until they are able to attend the course, most receive on-the-job training from people who have attended the course or previously held the position.

Although the infection control coordinator remains responsible for overall management of the program, creating and maintaining a safe work environment ultimately requires the commitment and accountability of all DHCP, and personnel are more likely to comply with an infection control program and exposure control plan if they understand its rationale.^10,28 Therefore, staff training is important, especially in large multiple-provider clinics such as military dental clinics. Personnel who are subject to occupational exposure should receive infection control training on initial assignment (when new tasks or procedures affect their occupational exposure) and, at a minimum, annually. The majority of clinics surveyed reported exceeding the mandated minimal requirement (that is, to provide training more than once a year), with 12.3 percent offering additional training at least six times a year.

Prevention practices. Protective wear. The ADA initially discussed the issue of DHCP’s wearing disposable gloves in a 1976 publication aimed at protecting DHCP from occupational hepatitis B infection.¹ The recommendations for wearing gloves, as well as masks, protective eye-wear and protective clothing have been expanded in subsequent ADA and CDC publications.^{2,4–10,29–32} In 1991, the Occupational Safety and Health Administration’s (OSHA’s) bloodborne pathogens standard mandated that PPE be used to protect DHCP from exposure to blood or other potentially infectious materials (OPIM).⁸ While other surveys on infection control practices have evaluated individual compliance with using PPE, our survey asked what types of PPE were provided to staff members. The most commonly used PPE in dentistry (gloves, masks, protective eyewear with solid sideshields and long-sleeved protective clothing) were available in 100 percent of the clinics.

Studies have shown DHCP to have varying rates of compliance in using PPE. However, studies conducted since 1991 have shown that compliance with using gloves is nearing 100 percent.^{13,14,16,17,22,23,25,33,34} Use of masks and protective eyewear also has increased significantly.^{13,14,16,17,19,33,34} In contrast, reports of wearing protective clothing have ranged only from 37 to 78 percent despite such clothing’s being an OSHA requirement.^13,14,17,34

Hand hygiene. Even though hand hygiene substantially reduces potential pathogens and is considered the single most critical measure for reducing the risk of transmitting organisms to patients and health care personnel (HCP), HCP’s adherence to recommended hand-hygiene procedures has been poor. In fact, an overall average rate of only 40 percent in hospital settings has been reported.³⁵ Although limited data are available for DHCP, compliance rates appear to be similar.^{13,17,19,25,26,34,36,37}

In 2002, the CDC began promoting the use of alcohol-based hand rubs as a means of improving compliance with hand hygiene in medical settings. Because USAF dental clinics are affiliated with medical clinics and hospitals, our survey included questions about the use of alcohol-based hand rubs in those clinics. Clinics were divided almost equally in the availability of alcohol-based hand rubs: 54.9 percent reported having them and 45.1 percent did not. In the clinics that had the hand rubs, 35.1 percent had them available in every operatory. Since most dental operatories have sinks, making alcohol-based hand rubs available in every operatory may not be indicated. In military and large group-practice dental clinics, alcohol-based hand rubs may be useful in examination rooms or radiology work areas, where many patients are seen in a short period of time and where frequent handwashing is indicated. Another indication may be in dental residency training programs, where staff members perform frequent patient checks.

Exposure control. Avoiding occupational exposures to blood is the primary way to prevent transmission of hepatitis B virus, hepatitis C virus and HIV to HCP in health care settings.^38–40 The type of blood exposure with the highest risk of transmitting a bloodborne pathogen is through a needlestick or being cut with a sharp object. Commonly used methods to prevent occupational exposure incidents, in addition to using PPE, include engineering and work practice controls. In the context of sharps injury prevention, engineering controls include sharps disposal containers as well as needles and other sharps devices with engineered prevention features, such as self-sheathing anesthetic needles, retractable scalpels and needleless intravenous (IV) ports. Work practice controls are behavior-based and are intended to reduce the risk of blood exposure by changing the manner in which a task is performed. A common example is using a one-handed needle-recapping technique (such as the scoop method) or a mechanical recapping device. All clinics in our study reported having sharps containers in place. Previous studies also have reported high compliance with the use of sharps containers.^13,17,25,34

Revisions to OSHA’s bloodborne pathogens standard clarify the need for employers to consider safer needle devices as they become available and to involve health care providers in identifying and choosing such devices.⁴¹ Many USAF specialists and general dentists administer IV conscious sedation, so it is not surprising that 47.6 percent of the clinics reported using IV safety equipment. Aspirating anesthetic syringes that incorporate safety features have been developed for dental procedures, but the low injury rates in dentistry limit assessment of their effect in reducing injuries among DHCP. Only 3.7 percent of USAF clinics reported using safety anesthetic syringes. The alternative methods—recapping needles using a one-handed technique or using a recapping device—still are acceptable and practiced in all USAF clinics.

Postexposure management. Although prevention is primary, postexposure management is a vital component of an infection control program to prevent infection after an occupational exposure incident involving blood or OPIM. Most civilian dental practices have to contract with an outside source such as an occupational health program of a hospital or an educational institution to provide management of, and follow-up regarding, occupational exposure incidents. USAF dental treatment facilities usually are located within or in close proximity to medical clinics, making arrangements with a qualified HCP to provide management and follow-up much easier. All USAF dental clinics reported having a written exposure control plan that included procedures for reporting occupational exposures and treating exposed personnel. In a 1995 study of civilian assistants and hygienists, only 83 percent of practices had written protocols for managing occupational exposures, and a recent ADA survey indicated that only 85.4 percent of responding civilian dentists had a specific written policy.^13,42 While not all USAF clinics reported having immediate access to postexposure prophylaxis (PEP), the word "immediate" was not defined, and it is likely that the five clinics (6 percent) that did not have immediate access to PEP do have timely access (that is, access within hours rather than days).

Instrument-processing practices. Cleaning before sterilization remains critical, because blood and other debris left on surfaces may interfere with the sterilization process. Using automated equipment (such as ultrasonic cleaners and instrument washers) to clean instruments is preferable to the more dangerous hand scrubbing. For instrument cleaning, 100 percent of USAF dental clinics reported using some type of automated equipment (for example, instrument washers, thermal disinfectors, tabletop ultrasonic cleaners).

Evaluation and surveillance. A successful infection control program should have valid means of measuring its effectiveness. All USAF clinics indicated compliance with a variety of evaluation and surveillance methods. Evaluation and surveillance offer an opportunity to improve the effectiveness of both the infection control program and dental practice protocols.

Dental unit water quality. All clinics reported taking measures to improve dental unit water quality, and nearly all (95.1 percent) were monitoring the water quality on a regular basis. This response is encouraging, because a recommendation for monitoring did not exist when this survey was administered. The 2003 CDC guidelines recommend following either the dental unit manufacturer’s or waterline treatment product instructions to determine the frequency of monitoring. The updated USAF Guidelines for Infection Control in Dentistry⁴³ also addresses this issue.

Inspection and monitoring. In the past, neither the ADA nor the CDC recommended that dentists perform surveillance for health care–associated infections; however, the new CDC guidelines do address this subject. While 92.6 percent of the clinics had an established surveillance program in place to monitor and report health care–associated infections, many were relying on self-reporting, which is not the most reliable means of surveillance.

With respect to spore testing, all clinics were in compliance with the current recommendation of at least weekly testing. Many clinics exceeded this recommendation and tested the sterilizers daily. In contrast, past studies have shown 35 to 53 percent of U.S. dentists and 71 percent of Canadian dentists to be in compliance with sterilizer monitoring.^{13,14,20,34,44}

	CONCLUSIONS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
In general, USAF dental clinics reported high levels of compliance with current infection control policies and procedures. Recurrent training, continual oversight, a highly motivated staff and teamwork are essential for reaching and maintaining these levels. Although compliance with recommended infection control guidelines is challenging, the results of this survey indicate that compliance is achievable, even in large group practices.