Possible Implications for Returning to Practice

by Dr Robert Carroll

As we review what we have learned from other countries and other provinces, it is quite apparent that dental offices will be allowed to open before Covid-19 is eliminated as a risk to patients and health care workers. Reopening our offices will likely be subject to several new requirements that public health agencies will have put in place in addition to all IPAC guidelines. An additional aspect of the new reality will be the much higher risk that your practice may be subject to an inspection by public health. To understand why, it is important to understand the circumstances that trigger inspections of dental offices.

There are two circumstances that result in an IPAC inspection being ordered for a dental office. The first is due to an outside complaint either to RCDSO or Public Health. Prior to Covid-19 this was the most common reason, but relatively rare. The second circumstance is due to the fact that Public Health has an obligation to interview patients when they receive notice of a diagnosis of infections such as HIV, Hepatitis [A,B,C], TB, STDs and some others. It is mandatory for registered health care professionals that diagnose these conditions to report this information to Public Health. Covid-19 has now been included as a mandatory reporting condition.

When Public Health is notified of a diagnosis of one of these diseases, they must interview the patient to try to determine where the patient may have contracted the disease, and everyone they may have been in contact with in the weeks leading up to the diagnosis. This is called contact tracing and Public Health has indicated that this will be significantly ramped up as a condition for reopening, and to ensure that workers as well as members of the public are protected. If the contact tracing of a Covid-19 positive patient indicated to Public Health that the patient’s dental office could be a suspect they would be required to inspect the dental office. In the past for the mandatory reported diseases it would require more than one patient under investigation to have the same dentist to initiate the office inspection and, fortunately, this has been rare. The low numbers of the population with those infectious diseases and the unlikely coincidence that more than one patient from the same dental office being diagnosed in the same time period is the reason few inspections took place as a result of this contact tracing. Covid-19, on the other hand, has a very high relative infection rate in the public and due to extensive testing going on it becomes more likely that a patient that attends a dental office may test positive to the virus at some time within the 14-day danger window. Even though it is much more likely that the patient would have contracted the illness from somewhere other than the dental office, the dental office would still have to be investigated before it could be ruled out. Adding to the chances of an inspection, is the fact that only a single patient diagnosis would be enough to trigger an inspection due to contact tracing protocol for Covid-19. In fact, a positive test could cause a patient to blame the dental office rather than taking responsibility for the lack of exercising proper protective measures in their own personal activities.

Due to the requirements of transparency legislation the consequences of a negative outcome from a Public Health inspection can be devastating. Just ask the dentists who have seen their names in the news and have consequently had to close their practices and notify patients of the need for them to have testing for some serious diseases.

However, there are quite a few things that a dental office can do to mitigate the risk of an unfavourable inspection.

The following are some recommendations:

  • Take advantage of this time to have a staff meeting to review all pertinent legislation including RCDSO Standard of Practice for Infection Prevention and Control, and Public Health checklists to ensure that your office is compliant in every respect. It may be wise to consider engaging an expert in this field to do an IPAC audit and advise on changes that need to be made.
  • The office can be proactive with patients by providing information to patients that will encourage them to attend the office and leave with confidence that everything possible was in place to prevent them from contracting any disease in your office. A printout of the sterilization records showing that each instrument package used on them had passed all necessary requirements to be safely used for their appointment may further build confidence in your office procedures. The goodwill gained by instilling confidence in your procedures and protocols could be invaluable should they contract Covid-19 subsequent to their dental visit and reduce the chances they would make a formal complaint against you.
  • Ensure that you have an adequate office IPAC manual that explains all protocols and has records documenting that all staff associated with the reprocessing of instruments have been trained and understand their responsibilities. An IPAC consultant can assist with this as well.
  • Ensure that all of your MSD sheets and equipment and instrument manuals are readily available and that each staff member knows where they are located and what the manufactures’ instructions are in regards to proper operation and maintenance schedules. Inspectors will ask to see those manuals because they want to ensure that staff members are using the manufacturer’s recommendations to guide their protocols. If an inspector asks a staff member who is involved in sterilization about the manuals and receives an answer that indicates these manuals are simply stored some place in the office and not being consulted, it would certainly send a negative message to the inspector and reduce the chance of a favourable outcome.
  • Ensure that all reprocessing records are maintained in such a way that they are readily available to the inspector and can demonstrate that your system or procedures meet the IPAC standards .

These mandatory IPAC requirements are very difficult for busy offices to meet. Even with perfect protocols in place, human error can occur. IPAC is very expensive as well. The need to upgrade sterilization equipment and renovate reprocessing areas to meet new requirements has made significant capital investment necessary for many offices. The day-to-day costs of PPE and other sterilization sundries has also created a significant increase in ongoing office expenses. Additional costs for Covid-19 specific requirements will only exacerbate that issue. The most significant cost in the long run however, may be the increase in staffing needed to cover all of the monitoring, documentation & report generation time that is now necessary.

Recently some digital and labelling products have come on the market that purport to help in this area. It may be worthwhile to investigate these products. While they have some things in common they differ in the degree to which they address not only the compliance requirements but also the reduction in labor cost issues. The best system for your individual practice will depend on the goals you want the system to deliver. Significant variables would include: the amount of automatic electronic recording of data as opposed to direct entry by staff and how that affects human error and staff time; the amount of built in resources to the system that provides additional guidance to the staff; the ongoing operational expenses versus cost saving and additional peace of mind.

Since I was a dental student in the late 60s, much has changed regarding what is considered essential and mandatory IPAC requirements even before Covid-19.  In fact, many dentists, including myself, wonder why this is all necessary. For decades prior to these regulations, dentists have been treating patients safely and there is no evidence that the public was placed in jeopardy in dental offices. I cannot remember any outbreak of serious infectious disease such HIV that was traced to inadequate infection control measures in a dental office in Canada. Covid-19 though has focused patients, health care workers, and regulators on IPAC requirements and whether or not the accepted standards of practice for dentists related are overkill or not is a moot question. Those are the requirements that are the “law” and we ignore them at our peril – whether it be for patient care, patient perception, or for our personal professional reputations and the value of our practice.

About the Author

After 28 years of general practice Dr. Carroll joined the RCDSO as Manager of Professional Relations in 2001. In this role Dr. Carroll advised the profession on the regulatory responsibilities for infection control including during the SARS pandemic. From 2008 until February 2019 Dr Carroll was Assistant Dean for Continuing Dental Education and Professional Relations at UofT. Infection control courses both live and on-line were among the courses that Dr. Carroll supervised. From January 2011 until January 2016 Dr. Carroll served on the Council of RCDSO and the ICRC Committee that dealt with complaints against dentists including those involving infection control issues. Dr. Carroll is currently an independent consultant to dental practices and dental industry on practice management and regulatory issues.