Respiratory hygiene and cough etiquette in the dental practice

By Dr. Katherine Schrubbe

Respiratory hygiene and cough etiquette are sometimes overlooked or minimized in the dental practice. However, especially now, when we are in the midst of cold and flu season, this is very important.

Infection control principles and practices are integral to the practice of dentistry and the provision of safe patient care, as well as to the dental team members’ health. In general, transmission of bloodborne pathogens (BBP) in the dental setting is rare, but this should not minimize the importance of consistent protocols for reducing the risk of cross-contamination.

In 2016, researchers reviewed the literature from 2003-2015 to identify published reports on the transmission of BBP in dentistry. They found the following cases:

• Patient-to-patient transmission of hepatitis B in an oral surgery practice, where the suspected cause of transmission was inadequate cleaning of environmental surfaces.
• Multiple procedural infection control breaches at a free dental clinic, resulting in three patients and two volunteers acquiring hepatitis B.
• Patient-to-patient transmission of hepatitis C in an oral surgery office, where there were many lapses in infection control.¹

The emphasis tends to be on reducing the risk of BBP transmission, but in another case report, a dental hygienist working in a practice in Washington developed active tuberculosis (TB) and transmitted it to a co-worker. TB is passed through airborne transmission, where droplet nuclei can remain suspended in the air for many hours.² According to the report, the dental practice had no personnel policies or administrative procedures in place for baseline TB screening or education. In addition, there were no records documenting whether dental staff members received baseline education about the signs and symptoms of TB.³   The risk of acquiring varied diseases or conditions as a dental healthcare worker is always present.

Reducing the risks
To prevent the transmission of disease and infection, it is important to be ever vigilant in carrying out recommendations of the Centers for Disease Control and Prevention (CDC) regarding dental healthcare personnel safety and standard precautions. Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin and mucous membranes.⁴ The elements of standard precautions include:

• Hand hygiene.
• The use of personal protective equipment (PPE), including gloves, gowns and masks.
• Safe injection practices.
• Safe handling of potentially contaminated equipment or surfaces in the patient environment.
• Respiratory hygiene/cough etiquette.⁵

Respiratory hygiene and cough etiquette are sometimes overlooked or minimized in the dental practice. However, especially now, when we are in the midst of cold and flu season, this is very important. Respiratory hygiene and cough etiquette, which were added to the list of standard precautions in 2007, are measures designed to limit the transmission of respiratory pathogens spread by droplet or airborne routes.^6,7  The elements of respiratory hygiene and cough etiquette target patients (and anyone accompanying patients) who may have undiagnosed respiratory infections, as well as any dental team members with signs and symptoms of cough or congestion.⁷  The strategies for implementation of this element of standard precautions is outlined below in the key recommendations from the CDC and is easily accomplished in practice.

CDC Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care, 2016; pg.9.

The CDC’s Key Recommendations include two specific to dental settings. The first focuses on ensuring the practice has the appropriate protocol and armamentarium for patients, or individuals accompanying patients, who have evidence of respiratory infections. The practice should provide these persons with the necessary items and notices to ensure they are queued upon entering the practice. The reception area should have signage reminding patients to cover coughs, use and dispose of tissues, and perform hand hygiene. The CDC has downloadable posters on covering coughs for reception areas that are informative and suitable for framing.⁸ The practice should have facial tissue, waste baskets and alcohol-based hand sanitizers available to patients in the reception area. Especially at this time of year, the recommendation to offer masks to coughing patients and providing space to separate these patients from others in the reception area is an excellent one. This demonstrates the practice’s commitment to reducing the spread of respiratory infections to others, and patients and guests will definitely be appreciative of these efforts.

The second key element emphasizes the education of dental healthcare personnel on the importance of containing and preventing the spread of respiratory pathogens during the provision of dental care^.7. It is vital that all team members are on the same page and understand the rationale for sound infection prevention measures to reduce the risk of acquiring respiratory infections and cross-contaminating patients. All elements of standard precautions play a significant role in preventing disease transmission to patients and dental team members. While there is a tendency to focus on items such as hand hygiene and PPE, the recommendations for integrating respiratory hygiene and cough etiquette into the dental setting are vital to complete the entire picture in promoting patient and staff health.

References:

1. Cleveland JL, Gray SK, Harte JA, Robinson VA, Moorman AC, Gooch BF. Transmission of blood-borne pathogens in US dental health care settings, 2016 update. JADA, 2016. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/pathogentransmission.pdf. Accessed November 28, 2017.

2. Centers for Disease Control and Prevention. Tuberculosis. https://www.cdc.gov/tb/topic/basics/howtbspreads.htm. Accessed November 28, 2017.

3. Merte JL, Croll CM, Collins AS, Melnick AL. An epidemiologic investigation of occupational transmission of Mycobacterium tuberculosis infection to dental health care personnel. JADA, 2014. http://jada.ada.org/article/S0002-8177(14)60040-4/pdf. Accessed November 28, 2017.

4. Centers for Disease Control and Prevention. Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html. Accessed November 28, 2017.

5. Centers for Disease Control and Prevention. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. https://www.cdc.gov/infectioncontrol/pdf/outpatient/guide.pdf. Accessed November 28, 2017.

6. Centers for Disease Control and Prevention. Oral health; respiratory and cough etiquette. https://www.cdc.gov/oralhealth/infectioncontrol/questions/respiratory-hygiene.html. Accessed November 28, 2017.

7. Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, March 2016.

8. Centers for Disease Control and Prevention. Influenza; cover your cough. https://www.cdc.gov/flu/protect/covercough.htm. November 28, 2017.

Editor’s note: Dr. Katherine Schrubbe, RDH, BS, M.Ed, PhD, is an independent consultant with expertise in OSHA, dental infection control, quality assurance and risk management.  She is an invited speaker for continuing education and training programs for local and national dental organizations, schools of dentistry and private dental groups. She has held positions in corporate as well as academic dentistry and continues to contribute to the scientific literature.