The Case of the Dirty Dentist

English: Putting toothpaste on a toothbrush. T...

English: Putting toothpaste on a toothbrush. The toothpaste is Crest Pro-Health Clean Cinnamon, 0.454% stannous fluoride, 0.16% w/v fluoride ion. Deutsch: Zahnpasta auf eine Zahnbürste auftragen. Русский: Выдавливание зубной пасты из тюбика на зубную щётку (Photo credit: Wikipedia)

Most of us wouldn’t think twice before checking that our silverware is clean at a restaurant.  But, when we sit in the dentist’s chair nervously eying the tray of gleaming stainless-steel instruments laid out beside us, we don’t pick them up and make sure they’re clean. We rely on our dental professionals to sterilize anything going into our mouth. That reliance may be a mistake.

Last week the Board of Dentistry performed a surprise inspection of oral surgeon Dr. Scott Harrington‘s Oklahoma office and found numerous problems with sterilization of instruments. The good doctor’s response when questioned?

“Dr. Harrington referred to his staff regarding all sterilization and drug procedures in his office,” the complaint read. “He advised, ‘They take care of that. I don’t.'” His attitude seems to be that not infecting his patients with blood-borne diseases is someone else’s job.

Other issues that came to light during the inspection included the doctors reuse of needles, disregard of expiration dates (one bottle of morphine expired in 1993) and his use of unlicensed assistants to perform tasks only a licensed dentist should perform, such as giving IV sedation.

Now over 7000 patients will undergo  testing to see if they contracted hepatitis or HIV due to the oral surgeon’s noncompliance with basic infection control practices.  In the meantime, don’t be fooled into thinking this is an isolated problem caused by one errant doctor.  On March 22, 2013 the Rhode Island Board of Dentistry temporarily shut a practice down after finding debris on multiple instruments in ‘sterile’ packages in exam rooms. No word on whether that dentist took responsibility for his office practice.

But, speaking of responsibility, how much responsibility do patients have to protect themselves from healthcare acquired infections? People have been trained not to touch someone else’s blood unless they wear gloves. People are encouraged to use barrier devices, such as condoms, during sex to prevent STD’s. Should our public health officials start a campaign to encourage patients to protect themselves during invasive procedures such as dental procedures, colonoscopies, and injections? If so, how can that be accomplished?

Recent articles have suggested patients ask dentists to prove they’re following guidelines in the care and maintenance of sterilization machines.  They’ve also advised patients to request to inspect the instruments prior to being removed from their sterile packages.  Other tips are to watch the dentist’s glove use, look at the overall office cleanliness, and quiz the dentist and staff as to how they handle reusable instruments. All excellent points, but it also requires a level of doctor-patient transparency and discussion that’s not usually seen. More importantly, how is your dentist going to react to his judgement and cleanliness being questioned?

In my work in the healthcare field, even the idea of a patient (or another healthcare team member) questioning whether someone has washed their hands before patient contact is a source of controversy. In a Swiss study, 76% of patients felt uncomfortable asking a nurse if she’d washed her hands and 77% felt uncomfortable asking a physician the same question. If patients don’t feel comfortable asking a simple question like that, do we really expect them to ask complicated, technical questions about sterilization procedures? Asking for clean instruments should be as easy as asking for a new knife or fork at a restaurant when the one on the table is dirty, but it isn’t.

English: South China Sea (May 16, 2006) - Hosp...

English: South China Sea (May 16, 2006) – Hospital Corpsman Steffon Corna sets up dental tools for a tooth extraction in the Dental Department aboard the Nimitz-class aircraft carrier USS Abraham Lincoln (CVN 72). Lincoln and embarked Carrier Air Wing Two (CVW-2) are currently underway in the Western Pacific operating area. U.S. Navy photo by Photographer’s Mate Airman Apprentice Brandon C. Wilson (RELEASED) (Photo credit: Wikipedia)

Will I stop going to my dentist? No. Will I ask to inspect the instruments for debris before my next procedure or cleaning. Yes. Hopefully he’ll understand, but if he doesn’t, I’ll tell him I’m holding him to the same standards I’d hold a restaurant to. I’m sure he doesn’t like eating off dirty forks any more than I do.



Did You Wash Your Hands?

As part of my ongoing kitchen remodeling project, visitors to my home now have the option to relax on couches and watch me cook. I joke that it prevents me from serving anything I drop on the floor, but my real worry is that I’ll forget to wash my hands appropriately (between handling meat and vegetables or the like) and someone will call into question my ability to safely prepare food.

Now I have a pretty good record in that I have no reported instances of my guests contracting a food related infection (at least not that I’m aware of). Unfortunately many hospitals can’t say the same when it comes to healthcare acquired infections or HAI’s. The Centers for Disease Control (CDC) reports that for every 20 patients in the hospital, one gets an infection. That’s two million infections annually. The simple act of handwashing breaks the chain of infection. So why don’t healthcare workers do it every time?

A quick scan of articles on the topic show handwashing rates of 37% to 77% for healthcare workers. Interventions to increase these numbers, including education, posters, and even personal hand sanitizer dispensers that monitor the number of uses, have all met with limited success. When no one’s actively paying attention to handwashing compliance, handwashing rates drop and infections increase.

Some institutions have encouraged patients to ask healthcare workers whether they’ve washed their hands before a treatment is given. I contend that the majority of hospital rooms and outpatient exam rooms have sinks or are equipped with hand sanitizing dispensers. It’s clear to most patients who has, and hasn’t washed their hands, but they’re too intimidated to demand only clean hands be placed on them. Since healthcare workers have shown they’re unwilling or unable to consistently wash their hands, patients need to demand it whether it’s comfortable or not.

No exceptions.

You can be polite:  “Did you want to wash your hands before you examined me?”
Belligerent: “Hey, I don’t want the cooties from your last patient. Wash up!”
Indirect:  “Did you see that Dr. Oz episode on handwashing? Amazing how many doctors don’t follow the guidelines.”
Matter of fact: “I don’t want to walk out of here with an infection, so please wash your hands.”

It doesn’t matter how you want to phrase it, if you value your health, you’d better say it. Every time. Don’t wait for your healthcare worker to protect you, protect yourself.

Clean Hands Save Lives

Healthcare’s Dirty Little Secret

Having a medical procedure should be safer than getting a tattoo.
My home state of New Hampshire was recently rocked by the news that 31 patients at a NH hospital had been infected with hepatitis while undergoing cardiac catheterization, an invasive procedure used to identify heart disease and defects. Specifically, they tested positive for Hepatitis C, a viral infection transmitted through blood that results in liver inflammation and can result in ongoing health issues. The threat of hepatitis transmission is used to discourage people from getting a tattoo or using intravenous drugs.  It’s not something that’s expected as a result of a hospital procedure. 
When I first heard this, I theorized the problem was due to inadequately sterilized equipment.   It’s no secret to those in healthcare that many invasive medical instruments are re-used and cleaned between patients.  Improper instrument cleaning was blamed in March 2009 when the Veterans Affair department confirmed that ten patients tested positive for hepatitis following colonoscopies. Even supposedly sterile, one-time use equipment has been implicated in disease transmission in the healthcare setting.  Infections from the use of urinary catheters, central lines, and mechanical ventilators occur with enough frequency that healthcare facilities enact policies and procedures designed to lessen the risk. In New Hampshire, hospitals self-report and post data on health care associated infections.  Yes, being the recipient of health care is a dangerous business. 
Though improper cleaning can be attributed to the pace of healthcare (decreased numbers of staff with less training and an increased workload) or financial constraints (doing things right costs money, doing them quickly, not so much), the cause of the Exeter Hospital hepatitis outbreak isn’t substandard cleaning,  rather it’s drug diversion. The theory being that a healthcare worker with an addiction to narcotics took the opportunity presented by multiuse vials and/or medication syringes that are filled but not given immediately, to inject a little for him or herself.  In the process, the infectged addict spread the hepatitis virus and now 31 people have a chronic liver disease.  This shouldn’t come as a huge surprise to anyone.  It’s not as if spreading disease through reused syringes and supplies is new. 
In 2009 at Rose Medical Center in Colorado at least 18 people contracted hepatitis when a drug addicted scrub tech switched out her used saline-filled syringes with drug-filled ones prepared for surgical patients.  An outpatient clinic radiology tech in Florida infected five patients while diverting fentanyl (a potent narcotic) for his/her own use.  Like any other crime, the ones who get caught are only the tip of the iceberg.
The Centers for Disease Control (CDC) report from 2008-2011 ( attributes outbreaks of hepatitis at outpatient clinics to the use of contaminated syringes to re- enter single use and multi-dose vials, the use of single use vials for multiple patients, and drug diversion by healthcare workers infected with hepatitis.  Obviously in today’s healthcare environment the patient can’t depend on their healthcare worker doing the right thing (follow strict infection practices) or the facility doing the right thing (random drug testing, especially of hospital staff that handle medications in areas known to be associated with diversion).  Seems like the concept of do no harm doesn’t apply to hepatitis prevention. 
If the victims of Exeter Hospital went to the CDC FAQ on Hepatitis C they’d see their risk factor for contracting hepatitis as “sharing needles, syringes, or other equipment to inject drugs.”  Unfortunately, the victims didn’t make the choice to share, the healthcare worker did. The site also cautions: “A few major research studies have not shown Hepatitis C to be spread through licensed, commercial tattooing facilities. However, transmission of Hepatitis C (and other infectious diseases) is possible when poor infection-control practices are used during tattooing or piercing.”   
Perhaps it’s time to add “transmission of Hepatitis C (and other infectious disease) is possible when poor infection-control and drug control practices are used in hospitals and other healthcare settings.” 
Until healthcare deals with this dirty little problem, it may be safer to get a tattoo than a medical procedure.