How has infection prevention changed over the last 25 years?
Barry Cockcroft takes us through a quarter of a century of infection prevention in dentistry and how far it has come in 2022.
In many ways 25 years ago it was similar to how it is now, but without the governance or evidence base. I think the governance around decontamination is really important and that’s why we ended up with HTM 01-05 and the CQC.
In the late nineties, it had already been through a period of significant change. When I graduated people didn’t wear gloves, many people didn’t have autoclaves in their practices and certainly nobody had washer disinfecters.
For a long time people had boiling water sterilisers, which, despite their name, didn’t sterilise. So there has always been change in cross infection protocols and dentistry as a whole is like that – there’s always change.
But what first really hit dentistry around infection prevention in the eighties and nineties was HIV and AIDS. People became very concerned about the transmission of blood borne viruses through dentistry.
The case that really set it off for dentistry was a case in America involving a dentist called David Acer. A number of patients attending his practice contracted AIDS and this caused huge uncertainty for the authorities and lots of difficulty for people infected with HIV.
After I took over as CDO, there was a move to improve standards. There were articles published in the BDJ. This showed, for example, disarticulated forceps after sterilisation with blood still in the hinges and things like that.
But the next really important thing was BSE and this was a real driver for change. From a cross infection control point of view, dentistry is effectively a surgical specialty. It has about a million patient contacts a week. So dentistry was really significant at the time with BSE and CJD being very prominent in the news.
We came under a lot of pressure from the DH advisory committee on BSE to either move to single use instruments or central sterilisation, both of which would have meant the end of dental care as we know it.
It was eventually agreed that if we could produce a document, which set high standards of cross infection control, they would accept that. But they also said that we had to find a way to ensure the standards were being met. So HTM 01-05 went together with CQC registration.
It was a combination of the evidence-based HTM 01-05 and CQC registration that meant we didn’t have to go down the route of single use instruments.
There was very little that was new in HTM 01-05. It was just pulling together guidance that was already published in different places.
Mouth is not sterile
One of the things I did as CDO was go out to visit practices. There, dentists were always keen to show me what they were doing to improve standards in their practices despite criticism from associations over HTM 01-05.
Another important thing to remember is that the mouth, as opposed to most of the rest of the body, is not a sterile area. Dental instruments do not need to be sterile when they’re used, but rather dental instruments need to have been cleaned and sterilised after they were used on one person and stored safely before they were used on the next.
I remember going to the Infection Protection Society annual conference, and saying that dental instruments are not sterile when they’re used.
There was a sharp intake of breath. But they’re not sterile when they’re used because the moment you put them in the mouth, they’re contaminated. You’re not trying to create sterile instruments. But rather instruments that have been sterilised since they were used the last time.
The one thing we did make single use was reamers and files. There was overwhelming evidence that they could not be cleaned efficiently and their use in proximity to nerve tissue was obvious.
The pressure did go away but it was a really difficult time.
Stood the test of time
I think the nice thing for me is that, although it was controversial at the time, HTM 01-05 has stood the test of time, and certainly through Covid although I suspect it is time it was revisited and updated.
Covid is not going to go away and we have to learn to live with it. It’s a virus that mutates, it’s always going to be there – just like flu. So in terms of transferring infection during treatment from patient to patient and based on evidence HTM 01-05 still stands.
Before Covid there was guidance to wear masks. I think what kind of mask is necessary will be down to more evidence and research.
At the end of the day, we will come out of the pandemic stage and get to where it is endemic. I get the feeling, personally, that in the long term there won’t be a hugely significant change in working practices and cross infection control protocols.
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