Greener Infection Control
After completing this chapter, the learner should be able to:
Define infection control as it applies to dentistry.
List the four tenets of infection control.
Design more eco-friendly ways of practicing dentistry.
Evaluate the environmental impact of common infection control processes used in dentistry.
DEFINITIONS OF INFECTION CONTROL
One definition of infection control is controlling the spread of disease-causing agents by performing specific procedures. Another indicates that infection control is a set of policies and procedures used to minimize the risk of spreading infections, especially outside of health care facilities. Infection control is not limited to health care, but rather should also be an important part of our personal lives, especially in our homes.
Although the principles of infection control remain unchanged, new technologies, materials, equipment, and data require continuous evaluation of our current infection-control practices. The unique nature of many dental procedures, instrumentation, and patient-care settings also may require specific strategies directed to preventing the transmission of pathogens among dental healthcare workers and their patients. Recommended infection control practices are applicable to all dental treatment settings.
TENETS OF INFECTION CONTROL
In 2003, the World Health Organization (WHO) established three very basic tenets of infection control. These included:
These tenets were a response to the severe acute respiratory syndrome (SARS) epidemic (see Chapter 4). The first actions of most health care workers are usually to help their patient. However, more than half of the victims during the first 6 months of the SARS epidemic were health care workers. Many came from areas where personal protective equipment (PPE), especially masks, were in limited supply. The patients were given masks, but not the practitioners. Because of an air-borne mode of transmission, the virus spread after close person-to-person contact.
Today, a fourth tenet can be added—protect the environment. Successful completion of certain infection control procedures is essential to protect the patient and the practitioner. However, this can involve generation of additional dental waste, introduction of potentially harmful chemicals, and adverse tissue reactions. Positive actions such as limiting transmission of pathogenic organisms can have negative outcomes for the environment, as well as for human safety and health.
A DIFFERING OPERATING PARADIMN
Hippocrates (460 BC-370 BC) is considered one of the most important figures in the history of medicine. He is often referred to as the “Father of Medicine.” He was the first to dismiss superstition and beliefs of the supernatural as causes of illness. Rather than punishment from the gods, he argued that disease was the product of environmental factors, diet, and behaviors.
One of Hippocrates’ classic writings included a seven-book treatise called Epidemics. It recorded observations made by a group of physicians traveling in Northern Greece. A famous quote from Hippocrates comes from this collection. He stated, “Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things—to help, or at least to do no harm.”
The “at least do no harm” posture can be applied to infection control in dentistry. Can environmental pollution and potential harm to humans be justified when performing common infection control procedures? By solving one problem, have you created two more?
The Occupational Safety and Health Administration (OSHA) has established a “thought process” or “points of consideration” when attempting to comply with one of its regulations. For example, if employee asks for a new type of PPE you can use three terms—reasonable, necessary, and appropriate—for evaluation. Is the request reasonable? Is it necessary? And, is it appropriate? Can we use this three-word approach to review the “greenness” of our infection control procedures? Do I have to do it? Can I do it differently and still achieve the desired effect? Can I do it less often? How can I do it more safely?
ENVIRONMENTAL IMPACT—POSITIVE, NEGATIVE, OR NEUTRAL
Outcomes generally fall into three general outcomes—positive, negative, or neutral. It is difficult to imagine an infection control procedure that would improve the environment. Most have a negative effect—increased waste, spread of harmful chemicals, or deleterious effects on humans. By altering a process or a material, can a potentially negative effect on the environment be avoided?
Change is rarely easy. It requires organization and dedication. It not only involves research, experimentation, and new materials or procedures but also behavioral change. Changing behaviors may be the most difficult.
Table 23-1 addresses the four steps or stages in the development of a more eco-friendly infection control program.
Table 23-1
The Four Steps in the Development of an Eco-friendly Infection Control Program
| Step | Step Description | Outcomes |
| 1 | Inventory of infection control practices | Will determine the nature and frequency of current practices and establish baselines (helps to measure improvement) |
| 2 | Develop a plan | All good plans have steps or goals that have measurable outcomes (always consider alternative methods and materials) |
| 3 | Implement the plan | Establish a timeline for implementation |
| 4 | Review and monitoring | Ensure that all issues have been addressed and monitored for change |
Reviewing infection control procedures may help identify pathways for change. For example, using disinfectant wipes instead of spraying disinfectants could reduce the amount of chemicals in the environment and exposure by patients and practitioners.
A successful plan not only addresses all possibilities for change, but also other issues. These include costs, including up-front expenses, such as new equipment. Proper training of workers is required for success; however, it also involves costs and lost work time. On the other hand, the time and resources spent on training will result in a smoother, quicker implementation.
Identify a reasonable amount of time and resources to establish the program. Having intermediate goals is often useful. Staying on task is necessary.
Once you think that the entire program is in place, review all points to establish completion. Monitoring will help determine if the desired effects are being accomplished. Review and monitoring may indicate areas for further improvement. Any plan should always be open to change.
EVALUATING SPECIFIC INFECTION CONTROL PROCEDURES
Improving the environmental impact of your infection control procedures includes elimination of some practices, using less, or employing a different product or procedure.
It is important to determine evaluation criteria for products and operations. This starts with a review of product attributes. Confirm performance and environmental criteria goals. Evaluate different methods. It may be wise to develop and execute a pilot plan. This decreases risks and should offer insight as to new equipment and the nature of the employee-training required. The feedback provided by a pilot project should help direct a more comprehensive plan.
Paper
A recent survey of dental offices reported that 12.8 pages of paper were included in a typical patient chart. By reducing this number to 6, an average office having 2000 patient charts would save 12,600 pages per year. All paper used should be made of chlorine-free pulp with a high recycled content. When possible, all paper should be recycled. Digital patient records could have a positive effect on the amount of paper used.
Sterilization
Proper recycling of oral contaminated instruments is an essential component of every dental office’s infection control program. Sterilization is an eight-step process—holding/precleaning, cleaning, drying, corrosion and inspection, packaging, sterilization, storage and distribution, and monitoring. The steps involve considerable use of energy, water, chemicals, and packaging materials. Unfortunately, there are limited ways to reduce the impact of sterilization. For example, there are no types of reusable instrument wrapping materials available as of this writing.
Using mechanical methods for cleaning reduces water and chemical use. Some large instrument washers can handle as many as 25 instrument cassettes and are more efficient than ultrasonic cleaners. They use less water and chemicals per instrument. Properly filled larger sterilizers can process more instruments in fewer loads than smaller units.
Radiology
Use of digital radiography instead of traditional film-based x-rays would help to reduce the impact on the environment. If using traditional x-rays, recycle fixer and developer solutions and lead foil from x-ray films.
Personal Protective Barriers
Many PPE are single-use, disposable items. Gloves and masks are not reusable. Protective eyewear can be cleaned and disinfected. Clinic gowns may be single use or reusable. Some single use clinic gowns are recyclable. Cleaning of the plastic material present is possible. An alternative is to use washable gowns. This, of course, uses energy, chemicals, and water. Energy Star washers and driers, which are more energy efficient should be used.
Regulated Medical Waste
Only about 3% of waste generated in dental offices is regulated medical waste requiring special holding, neutralizing, and disposal methods (see Chapter 16). That means the remaining 97% can enter the normal waste stream. Some waste materials are biodegradable and thus can be recycled. Using less means less to throw away.
Environmental Asepsis
Use of physical barriers can protect clinical contact surfaces from contamination. Disinfection will kill and remove potential pathogens. Both have advantages and disadvantages. Most dental offices use a combination of physical barriers and disinfection.
Applied and removed properly, physical barriers will not allow soiling. They are single-use, disposable items and thus increase the amount of waste generated. Most physical barriers are sheets of plastic. Aluminium foil has limited application, but can be recycled. Always limit the amount of physical barriers used.
Disinfection involves use of chemicals and PPE and exposure of patients and practitioners to chemicals. As described previously, disinfectant wipes release less chemical into the environment. An acceptable disinfectant should be able to kill Mycobacterium tuberculosis var bovis in 10 minutes or less, not be deleterious to surfaces, and be as benign to humans as possible. There are no perfect disinfectants. Offices should limit disinfectant use.
FUTURISTIC THINKING
There are a limited number of changes that dental offices can make in order to reduce their impact on the environment and human safety and health. New materials and processes are developed every day. It is imperative for offices to stay current with emerging developments.
Canadian Dental Association. Eco-friendly dentistry: not a matter of choice. JCDA. 2007;73:581–583.
Daschner, D.F. Environmental protection in hospital infection control. Amer J Infect Control. 2000;28:386–387.
Eagle, A. Clean + green. Health Facilities Management. 2004;17:25–28.
Lee, B.K., Ellenbecker, M.J., Moure-Eraso, R. Analyses of the recycling potential of medical plastic wastes. Waste Management. 2002;22:161–170.
Smith, M. Waste not. Hospitals reduce, recycle and manage waste. Health Texas. 1992;48:10–18.
Transcedentist. A dentist for tree huggers. Available at http://www.springwise.com/eco_sustainability/a_dentist_for_treehuggers. Accessed June 2008.
Review Questions
______1. Which agency developed the three basic tenets of infection control?
______2. Which of the following is not one of the three tenets of basic infection control?
______3. Which agency developed the three-word scheme for evaluating infection control methods and materials?
______4. How many pages would the average dental office save in one year by reducing the number of pages in patient files by one-half?
______5. What percent of waste generated in a dental office is regulated medical waste, thus requiring special handling, neutralization, and disposal?