GDPUK.com Opinions: Tony Kilcoyne
Tony Kilcoyne, an experienced practitioner, puts forward some new and possibly controversial ideas about dental practice cross infection protocols for the future.Should dentistry look back to some of Florence Nightingale's ideals?
Dr. Tony Kilcoyne is a Specialist in 
Prosthodontics in Haworth, West Yorkshire and takes referrals for complex cases from all over the UK.
He qualified from Sheffield University in 1983 and has undergone further postgraduate training and experience in the UK and USA, from the Leeds Dental Institute and Eastman Dental Institute to New York University and the University of Pennsylvania, gaining a wide experience of progressive Dentistry. He Lectures/demonstrates regularly on Advanced Restorative Techniques, Tooth Whitening, Medico-legal and Clinical Governance topics too.
He is an elected dental member of the GDC, Clinical Director for online verifiable CPD at www.4everlearning.com and a Dental VT Adviser in Dewsbury for over 17 years. Despite all these other commitments, Tony still spends the majority of his working week treating patients and firmly believes what is bad for Dentistry is bad for Patients too.
Introduction: Cross-Infection controls are likely to need a major step back in the future, to achieve excellence in basic hygiene methods, where increasingly myopic regulatory requirements are often too focused upon miniscule theoretical risks rather than high-contamination risks between patients. What we need in Medicine and Dentistry is to go back to the Florence Nightingale approach of practical solutions to the main Cross-Infection control issues. These issues are gaining prominence publically, from the rise in Hospital Acquired Infections causing thousands of deaths a year, to the GDC making it part of Dental registrants’ CPD core requirements for public protection.
Yet despite this obvious need, from Florence Nightingale’s audited observations in the Crimean war to recent National Audit Office reports on Cross-infection, there is still the phenomenon that many clinical staff do not apply basic hygiene practices consistently. Is this just resistance to change, overconfidence or some kind of feeling of futility associated with ever-changing guidelines that in many instances are not evidence-based or risk-assessed so that they can be applied in a prioritised fashion ?
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If we accept the premise that our aim is to ensure that anyone walking into our Practice/Clinic right up until they leave, do not acquire any diseases or infection that they did not arrive with, then we must protect them through their whole journey with us. To me these include crossing the threshold into the reception/waiting areas, the Surgery and the non-public areas too, such as staff-room/cleaning areas.
To date, most guidance such as BDA’s A12 has simply not emphasised cross-infection control issues beyond the Clinical areas. Surely we must ensure, where possible, that the risks of cross-infection in the Dental Practice environment are less than (as opposed to an impossible zero !) those in every-day life, such as using Buses and Supermarkets to public toilets and restaurants say. This is a subtle but important goal. Realistically where disposal/covers are impractical, dis-infection is the most effective way to protect the public. Remember that Dis-Infection simply means surfaces are deactivated/diluted down to a level where one person is not then infected from another. Proportionately there is little point going to extreme measures to sterilise individual dental instruments, when the reception door-handle or desk is going to be grossly contaminated by someone who has previously put their fingers in some personal orifice, or possibly worse, their mouth after a scaling !
Apart from coughs and sneezes, contact by hand is the commonest vector to transmit infective doses from one person to another. We may wear gloves for treatment, but our Reception and Staff areas are relatively unprotected and therefore more risky. But what can we do that is both practical and effective? This is a discussion that has yet to take place Professionally and instead of coming-up with obstacles to why we can’t do anything because it’s too difficult or futile, we should really be looking at practical solutions that can make a difference to this very real challenge. So here are some further thoughts on this aspect to start the ball rolling.
Without doubt, it is patients and visitors that are the main problem, they come in with the variety of infections that are a risk to others, so shouldn’t we be dis-infecting them as a first step? As Florence Nightingale found back in the 1850’s, cleaning the environment alone can reduce the incidence of wounded soldier deaths by some 20%, but then she found also scrubbing the Doctors and visitors with carbolic soda reduced death rates equally again, thus lowered overall from 40% down to 2%!
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So should we go back to Florence Nightingale’s principles and clean the people too?
Fortunately Dentistry is rarely about life and death, but when some patients can successfully sue the NHS for £5million for an acquired infection, the accusations for dentistry from acquiring Hep.C to Cold Sores, are almost inevitable.
In my view, we could quickly make it the “norm” for patients/visitors to rub their hands with an alcohol/chlorhexidine gel that conveniently evaporates away, both on entering the Practice and leaving the Surgery too. Even in Harvey Nichols in Leeds, visitors to their toilets are requested to wipe the seat down afterwards with the antiseptic wipes provided, as well as clean their hands. Shouldn’t we ask this too ?
Another serious issue is staff (including dentists) coming to work in uniform and leaving in the same uniform too, carrying god knows what into and out of the Practice environment. I still commonly observe this in many areas I visit and I’m sure you can too.
If uniforms cannot be laundered on site, then there are specially designed bags that dissolve in prolonged contact with water that staff can use to take uniforms home and simply place in a separate (hot) wash without touching. Yes more uniforms and shoes will be needed or shirts/pants if you prefer non-clinically looking attire, but workwear should not be worn outside of the Practice. Then we have to think about pens, records, handling payment (ideally done before treatment and after hand-rub), children’s toys, leaflets in reception and patient toilet areas, perhaps cleaned every hour and all door handles wiped-down too. This is something that needs individual risk-assessments and may mean removing some items if they are regarded as a vector for cross- infection that cannot be easily controlled.
Summary : We should aim to make any cross-infection risks LESS than those found outside the whole Dental Environment. This can be realistically achieved IMHO and indeed this increased activity/visibility may go a long way to re-assuring the public that their Dental Practice/Clinic is indeed a safe environment to be, relatively speaking. So far, Dentistry has faired much better than Hospitals when it comes to public health risks and bad press, but we should not rest on our laurels or wait for a disaster to happen publically – we should act preventably with targeted resources where they are most likely to make, and be seen to make a difference. That means workwear only worn at work, cleaning all dental environments optimally but also cleaning the patients and visitors too!
Let’s make Florence Nightingale proud some 150 years later and set a good example.
Agree with the alcohol hand wash by doors Tony but heard that some hospitals reported it mysteriously running low -not beyond belief that it was being used orally as well.....
I agree that what we do and how we do it should be as evidence-based as possible and where that objective evidence is lacking or poor, we should proceed with caution so that anything we do is proportional to the risks. Also any systems should NOT be unduely onerous on those who provide clinical care and/or divert excessive funds away from the direct provision of good dental services.
There are certainly concerns that Scotland hasn't got that balance optimal :o
So far I have found asking patients and visitors to use our hand-rubs on entering the Practice to have been very well received - this has been quite suprising actually and even our postman has asked if he can pop-in and use the facility even if he hasn't got mail for us! We also get patients to do this when they leave the Surgery too, before going into reception and the smell/taste on their hands seems to instinctively stop them putting fingers in their mouths, be they adults or children!
Our staff varied in their response to the rule of no workwear being worn outside the practice if it has been worn at all inside the practice but all have now got into that routine and it's not a problem. Ironically we did a dental/educational school visit (as part of reaching out into the community)weari ng our uniforms, but they were all laundered first and didn't go back to work that day without being laundered again!
We have routines for wiping down surfaces in reception, protocols for the patient toilet areas and staff areas and wiping down certain door handles too, which we are still analysing to get an optimal effect without going overboard either.
This has some additional costs in time and effort initially and the hand dispensers are probably the largest initial cost and works out at about 1.2p per dispense, but the vast response/feedback has been much more positive than even I expected/hoped for from the public and they have found it very re-assuring too rather than worrying, which given some of the acquired infections headlines one reads about hospitals and cruise ships, was a concern.
We are still refining and collecting feedback from our patients/visitors but I thought this update now might be helpful. It is very much seen and communicated as a preventive measure and my feeling is that Dentistry has always been at the forefront of "sensible" prevention in it's outlook.
If anything is going to work in Primary Dental Care it has to be economic (time and costs), practical to do, be proportionate to any risks and be as evidence-based as possible.
Compared to what Scotland is planning/imposing, I believe we are ahead on all of those measures :)
Tony Kilcoyne
Haworth, Yorkshire.
now we have the prospect of having to build or incorporate local decontamination units ( LDU's ) in each and every practice. I would refer anybody interested to access article in latest edition of Scottish Dentist magazine to check out scientific grounds (or lack of).
Its might be coming your way soon.
gordon cully
Ali
Bradford
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