Seeking safe dental care: infection control essential and expensive.

A classic scene in the 1976 hit thriller, "Marathon Man," had Sir Lawrence Olivier menacing Dustin Hoffman with a dental drill and pick. With Hoffman restrained in his chair and his mouth pried open to the probing instruments, Olivier -- portraying a murderous Nazi fugitive and former dentist in the film -- kept asking one question over and over again: "Is it safe?"

While used in totally different context in that particular movie, the question posed, "Is it safe?", seems to be on everyone's mind these days in regards to dental care. And well it should be.

A spate of recent articles in newspapers and magazines as well as television news programs and shows like ABC's "Prime Time" have raised questions about the safety of going to the dentist. What are the risks of contracting hepatitis or other infectious diseases from your dentist. And what about AIDS -- either from your dentist, an attendant or a previous patient?

The Kimberly Bergalis case in Florida in which Ms. Bergalis died earlier this year after contracting AIDS -- allegedly from her dentist -- sent a scare wave across the country. While the Centers for Disease Control in Atlanta concluded that a strain of virus found in Bergalis' dentist, who had AIDS, was "closely related" to a strain taken from Ms. Bergalis, it was never proven conclusively that Ms. Bergalis did contract the disease from her dentist or, if so, exactly how it may have been transmitted.

Still, there is a great deal of fear and concern about safety in the dentist's chair, and it has caused sweeping changes in the dental industry -- changes that impact not only the patient but also private practice dentists, indemnity plans and pre-paid plans.

The "hot button" in the dental industry today and the issue on which most news reports have focused is that of sterilization, specifically the sterilization of dental handpieces and related instruments such as air/water syringes. In dealing with this subject, the media's eye has been trained largely on whether or not dentists are heat sterilizing their handpieces.

While infection control is certainly extremely important, there is another side to the issue which those outside the dental industry may not even stop to consider. That point is cost.

Over the past couple of years, dental practitioners have had to make drastic and expensive changes to their office protocols in order to comply with guidelines set forth by the American Dental Association, the California Dental Association, the Centers for Disease Control and OSHA regarding sterilization and infection control.

The dilemma is: who pays for the additional costs? In the case of managed dental care, is it the plan providers? The corporate and individual purchasers of the dental plans? The dentists who are contracted to provide service under pre-paid plans? Or the patients in the form of a "per visit" or "per treatment" sterilization fee?

The purpose of this article is two-fold. First, it is designed to examine closer the whole issue of sterilization -- what it is, how it is done, and why it is absolutely essential for safeguarding the patient's -- and the dentist's and attending personnel's -- safety and well-being. Secondly, it addresses how dentists and dental plans are being affected by the increased costs of sterilization and infection control and how those costs are a matter of real concern today for dental plan agents, brokers and others in the industry.

Why the Concern

Infection control has always been a primary concern for dental care providers, but the general public has never been quite so aware of it as it is today. Why? In large part, the red flags have been raised due to the increasing number of HIV and AIDS cases and the fear of contracting such a disease from exposure to blood and other body fluids.

Recent government and media reports have generated unprecedented concern about HIV and AIDS, and the dental office has been spotlighted as one possible danger area.

During dental procedures, there is the potential for contamination from saliva and blood. In addition, blood spattering may occur. Dental personnel, therefore, have to assume that where blood and saliva are present, there is the potential for transmission of infectious diseases.

Because the HIV virus, the hepatitis-B virus and other such infectious diseases can be transmitted in any circumstances in which the exchange of blood and body fluids is possible, and because it is the patients who do the bleeding, most protective measures have been aimed at protecting the dentist and attending dental staff rather than the patient. The Bergalis case, however, changed all that. Risks of transmission today can be categorized in three ways:

1) patient to patient

2) staff members to patient

3) patient to staff members

Today, all patients need to be treated as potentially infectious. In like fashion, patients should be on the lookout to make sure that their dentists and the attending dental staff are using protective clothing and barrier techniques (to be discussed in more detail shortly) to assure both parties' safety.

There are various signs and symptoms of HIV and other infections, and dentists must be alert to them. By recognizing such symptoms, they will be better equipped not only to diagnose and treat the patient, but also to take all necessary precautions to lessen the risk of transmission of any infectious diseases.

Before any patient treatment is rendered, the dentist should obtain a thorough medical history of that patient. A sound approach to the treatment of infectious patients requires an assessment of the patient's condition based on reasonable and informed medical judgements.

Because the nature of AIDS, for example, is to impair the immune system, any surgical intervention to the body may, as is presently understood, have the effect of deteriorating the health of the patient. Dental invasive procedures, including work with a dental drill or other instrument that draws blood, could, therefore, pose a risk to an HIV positive or AIDS patient.

For this reason, it is important that all treatment of a patient who has been diagnosed positive for AIDS be pre-approved by the patient's physician.

There are other procedures that present little or no risk, either to the patient or to the attending dental personnel (for example, removal of retainers, dental impressions and orthodontics).

Use of Protective Barriers

Protective barriers (universal precautions) reduce the risk of exposure to potentially infectious materials to the dentist's skin and mucous membranes. Specifically, such precautions reduce the risk of exposure to blood, body fluids containing visible blood and other fluids that could be potentially dangerous.

Examples of protective barriers are gloves, gowns, face masks and protective eyewear such as goggles. While they cannot prevent penetrating injuries from needles or other sharp instruments, gloves effectively reduce the incidence of contamination of hands. Face masks and protective eyewear also reduce the incidence of contamination of mucous membranes of the eyes, nose and mouth.

Concurrently, use of these protective barriers protects the patient, as well.

Doctors routinely change gloves during treatment and between every patient to assure safety. Hands are also washed before gloving and after the gloves are removed. The rationale for hand washing after gloves have been worn is that gloves often become perforated during use and allow bacteria to enter beneath the glove material and multiply rapidly.

If gloves are torn, cut or punctured during dental procedures, they must be removed immediately and the hands thoroughly washed. The hands must then be re-gloved before the dental procedures are resumed.

Other Safety Precautions

Professional dental associations and organizations such as the American Dental Association (ADA) and the California Dental Association (CDA), as well as the Centers for Disease Control and OSHA, have all issued guidelines for sterilization and infection control in dental offices, including the use of the protective barriers outlined above. Except for OSHA requirements, these are guidelines only and not mandatory procedures. However, they are generally adhered to today by dentists and support staff.

A number of other guidelines have been set forth by these organizations to assure doctor/patient safety, and most of them have been adopted by dental care providers throughout California and across the country. Some providers have also expanded upon the recommendations to provide greater protection to all parties.

In addition to employing protective barriers, many dentists have instituted other protocols for infection control, such as:

* Face masks, goggles or faceshields are worn by all dentists, hygienists and assistants.

* All instruments used in connection with dental treatment are sterilized. They are kept sealed and sterile in bags until unsealed for usage on the patient. After use, they go through a complete sterilization cycle before being used again.

* The sterilization cycle involves scrubbing and disinfecting with a germicide/disinfectant, then autoclaving for the prescribed length of time needed to achieve sterility (autoclaving will be discussed more in detail later in connection with handpieces). All instruments that cannot be heat sterilized due to the nature of the material or side effects of the heat process are sterilized 8-10 hours overnight in an approved disinfectant solution.

* All counter tops, lights, chairs and other surfaces are wiped and cleaned with a germicide/disinfectant continuously as well as in between patients.

* Dentists, hygienists and staff are updated continuously and given continuous education in infection control. An infection control consultant should regularly inspect the firm's offices to insure that they conform to the highest standards of sterilization and protective procedures.

* All dentists and staff that assist the dentists have should have received the hepatitis-B vaccine or, in the case of new employees, are in the process of receiving it. Follow-up boosters should also be provided for those employees who have received the vaccination series previously.

* Spore testing is conducted regularly to insure the efficiency and effectiveness of the sterilizers. In this process, a vial or strip of bacteria is run through the regular sterilization cycle for dental instruments. Afterwards, it is sent to the contracting firm for testing.

If the results are negative -- in other words, if there has been no bacterial growth--then the sterilizer is working properly and quality sterilization is assured.

Waste Disposal

Another major consideration for dental care providers is the disposal of hazardous materials such as needles, scalpels and blood-contaminated debris. Although guidelines for the disposal of contaminated materials are not strictly defined for the dental field, the regulations regarding disposal of "infectious" waste can be imposed on any practice or operation for non-compliance as set forth in the Health and Safety Code.

In addition there are policies regarding waste management that have been established by various California and local health departments and agencies, and dental facilities must adhere to them.

Because testing of blood samples is not routine in dental offices, all blood-contaminated material should be treated as potentially infectious waste.

All disposable sharp items such as needles, scalpels, broken glass and any other items that can cut or injure must be placed in rigid, puncture-resistant sharps containers. The same is true for other items that are heavily soaked in blood or any items from a patient with a known infectious disease.

When filled, the sharps containers should be sealed with non-removable lids for pick-up by an infectious waste disposal company contracted by that dental facility. It is important that proper waste disposal companies be contracted because the dentist is responsible for his waste material even after it has been picked up by the waste disposal company.

Dental Handpiece Sterilization

Dental handpieces have come under intense scrutiny because they very often cause bleeding. The logical question one might ask is: if blood is inside the handpiece, couldn't it infect the next patient? The answer is: yes . . . if not properly sterilized.

The American Dental Association has recommended that both high- and low-speed dental handpieces be autoclaved to assure patients' safety. In the autoclave sterilization process, instruments are cleaned ultrasonically or scrubbed and then dried. Afterwards, they are put in a special sterilization pouch and either placed in a steam-heated autoclave unit or a chemical vapor sterilizer at appropriate temperatures for proper time periods.

While both of these methods -- autoclaving and chemiclaving -- have been shown to be effective in controlling infections, they are not universally used. As was brought out in those recent news reports questioning the sterilization of handpieces, a large number of dentists don't heat sterilize their handpieces. Rather, they simply wipe off the outside of them with disinfectant.

Why? Primarily because of the high costs involved in autoclaving and the shortened life of the handpiece.

That leads us to the second part of this article: namely, infection control costs and who pays for them.

The High Cost of Infection Control

Protective barriers, steam or chemical vapor sterilizers, autoclavable handpieces and other such infection control measures are not inexpensive. In fact, they are quite costly. On the average, a dentist pays approximately $18 per patient visit for sterilization measures.

Handpieces, for example, generally cost between $500 and $800 per unit. A dentist with an average size clientele now has to purchase approximately 15 to 20 autoclavable handpieces so that he has enough of them to be heat sterilized between each patient. The total initial cost for handpieces alone can easily exceed $10,000. Sterilizers can easily cost $3,000 to $5,000 each, and an office may need more than one.

Add to that the costs that dentists need to pay for other items -- special uniforms or protective clothing, for example, with accompanying laundry services, bulk quantities of gloves, masks and protective eyewear, disposable items, an increased number of dental instruments to keep up with patient flow and sterilization cycles, sharps containers for waste disposal and waste disposal services -- and you can begin to understand the problem.

That doesn't even take into consideration other ancillary expenses such as providing for vaccinations for exposure-prone employees, employee training and continuing education, increased insurance premiums and Workmen's Compensation and the hiring of additional staff personnel to insure proper compliance with all recommended safety procedures.

On the one hand, patients are clamoring for better protection from HIV, AIDS, hepatitis-B and other such diseases. They want to feel safe when they go to their dentist.

On the other hand, they have no idea of the extra costs involved. Should they have to pay more to receive extra protection? Isn't that what they're entitled to?

The fact of the matter is that infection control is not an option. It is not something that a dentist can "unbundle" or separate from his other office charges. When a patient visits a dentist for whatever reason, that patient expects -- and deserves -- to receive high quality, safe treatment.

It is for this reason that most insurance companies and pre-paid dental plans state that the costs for infection control must be incorporated into their regular fees.

Some Ideas for Cost Control

In some dental offices, dentists are trying to absorb costs because they do not want to raise their fees and, perhaps, stand the risk of losing patients. Other dentists look at the increased costs for handpiece sterilization and infection control as simply increased overhead costs and believe fee increases are justified. Still others favor infection control surcharges.

Either way, the patient pays.

The major pre-paid dental plan providers in California are split on the issue. The providers of such plans are required to be accountable for costs so any increases would have to be fully justified to be acceptable to plan members. At the same time, agents and brokers are hesitant to see premiums raised for expenses which could be considered usual and customary.

Some of the ideas that have been proposed to date for resolving the issue are as follows:

* Charging a set fee of $4.00 to $5.00 per visit per plan member for "office visit/sterilization". One problem that exists with this proposal is that no such charges were originally included in the plan and now the provider is suddenly charging fees for an unlisted treatment code.

* Adding a percentage to the plan's premium (i.e. 5%) for sterilization which would then be passed on to the provider.

* Increasing co-payments overall to encompass increased sterilization costs.

Still another idea that has been bantered about is for the plans to reimburse contract dentists for infection control costs in lieu of co-payments or increased capitation. That, however, would increase the overall cost of the plan which, in turn, would increase the premium.

There is a valid need to increase allowances per dental procedure to adjust for the added costs of infection control. However, upscaling dental plan benefits could be slow in coming because the dental plans must determine: 1) if they can raise their rates and still remain competitive; 2) if they raise the rates, what exactly the rate increases should be; and 3) if neither of the above, should the plan benefits be decreased to offset the increased costs of infection control.

Financial Hardship for Everyone

If and when it is decided where the costs will come from to pay for infection control, one thing is certain: it will impact everyone in the dental industry from pre-paid dental plans to indemnity plans to private practice dentists.

As it stands right now, many private practice dentists simply cannot afford to pay the extra costs for sterilizable handpieces and autoclaving. That's why some continue to wipe down their handpieces with disinfectant rather than autoclaving them, and why others autoclave older-model handpieces and other instruments that are not designed to withstand such high temperatures.

Many dentists are simply cutting costs wherever they can. In the process, however, they may not be complying with OSHA regulations or providing the quality assurance their patients deserve.

Pre-paid plans with staff model offices (offices owned and operated by the plan participants), or IPA offices (offices that are contracted by the plan) or, a staff model and IPA combination, are better equipped to handle escalating infection control costs because of their size and financial resources. They are also better able to implement the most modern up-to-date infection control practices and procedures and to properly monitor their facilities to assure compliance to their high standards for infection control.

The costs for sterilization and quality assurance are not easy for anyone to absorb, but they are not going to go away.

Neither the American Dental Association nor the California Dental Association has taken a position on the issue, yet it is coming to a head and the dental industry will have to deal with it.

Changes in Store

Group members, agents and brokers need to be aware of the situation and appreciate the fact that infection control has wrought incredible changes not only in dentists' office protocols but also in the overall cost of safe dentistry today.

They also need to realize that such changes have caused managed dental care providers to re-evaluate their premium rates and to explore ways of restructuring their plans to cover infection control practices.

Whatever may ultimately be decided, the patient stands to benefit the most -- by receiving the safest, highest quality dental care available.

Frank Pellkofer is President of Western Dental Services Inc., and Robert Stalcup, DDS, is the Operations Director.

AIDS in the Workplace

AIDS Project Los Angeles' informative seminar for employers is going on the road.

Developed by Lee Klosinski, manager of APLA's Prevention Education Programs, and Speakers Bureau Coordinator Ken Mosesian, "AIDS in the Workplace" is aimed at bringing knowledge and awareness to management of any type of business on issues related to HIV and how they affect the work environment.

Topics during the two-hour seminar include legal concerns and the rights of HIV-impacted workers and their co-workers, confidentiality issues, first aid, workplace disclosure and compliance with the Americans with Disabilities Act. The Program was designed to be flexible, so that it can be adapted to suit each employer's needs.

Increased Demand

Klosinski said that the concept for "AIDS in the Workplace" was based on a program that was funded by a grant in the mid-1980s. "Unfortunately, the grant wasn't renewed and the agency wasn't in a position to continue the program," said Klosinski. "Now, due to an increasing number of phone calls requesting this type of prevention education, we are happy to be able to offer the seminar once again."

Targeting prospective employers and marketing the program are two of Klosinki's main concerns.

"Surveys are showing that getting in the door at most of these companies is based on either a crisis situation or from employees requesting this type of a seminar," said Klosinski. "We need to call upon our vast pool of volunteers to request that their employers invite us into their companies to do workplace education."

Volunteers Trained

The 12-hour training for "AIDS in the Workplace" is designed for volunteers who have completed Hotline or Speakers Bureau training. The first team of volunteers, which concluded its training in February, includes volunteers who represent the fields of medicine, law and insurance, as well as APLA staff members and volunteers.

Dean Nelson, a Speakers Bureau member, is a freshly trained volunteer for the program. Nelson, who is HIV-positive, was drawn to the program because he has been the object of discrimination in the workplace.

"Education about HIV is absolutely essential," said Nelson. "People who are HIV-positive have a right to a job and to continue working."

Other volunteers trained for presenting the seminar include Clare Faulkner, Les Kalman, M.D., Neal Kaminsky, Michelle King, Judie Klapholz, R.S. Lomax, Tom Price, Shane Sawick, Scott Sax, Judi Vessa and Geoffrey Martin Cyr.