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BDA calls for clarification over decontamination

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Susie Sanderson

The British Dental Association (BDA) is calling for a full review of the evidence base for the HTM 01-05 guidance document on decontamination in dental surgeries.

The BDA has written to the Department of Health renewing its 2007 call for a National Institute for Health and Clinical Excellence (NICE) review of the evidence.

It has emerged that three areas of the guidance have already been amended before the document is even printed.
 
The three changes to the guidance are:
• The use of potable water for the rinse stage of decontamination is now permitted. This is a climb down from the previously intended requirement for reverse osmosis and freshly distilled water, after studies showed low concentrations of endotoxins in England's potable water supplies.
• The period for which instruments can be stored after they have been processed in a validated vacuum steriliser has been increased from 30 days to 60 days.
• The revision of the requirement for two sinks for decontamination to allow the option of two bowls incorporated into a single unit instead.

Concern about these changes has been heightened by a consistent failure by the Department of Health to publish the references that they say form the evidence base for the document, despite repeated requests by the BDA for it to do so.
 
Calling for the guidance to be referred to NICE, BDA executive board chair Dr Susie Sanderson said: 'It is telling that changes to the content of HTM 01-05 have had to be made already. The changes expose the uncertain evidence base on which the document is founded and will be a cause of great concern to dentists. These doubts can only be exacerbated by the failure of the DoH to publish its evidence base for the document.
 
'This guidance will apply to family dentists and public dental facilities alike, so complying with it will cost both dental practice owners and the taxpayer significant amounts of money. The dental profession is absolutely committed to the highest standards of patient safety and is happy to invest in pursuit of those standards.

‘But the investment has to be in changes for which there is a robust evidence base. To establish that evidence base the BDA believes the guidance must be looked at in detail by NICE.'

A DoH spokesperson said: 'We are updating our guidance on decontamination to ensure dentists have the latest scientific advice available at their finger tips.

'We constantly update our advice as clean, safe care is a standard that patients have a right to expect in all healthcare settings. Over the last five years, we have introduced a Clean, Safe Care Strategy for reducing infection and we now have cleaner hospitals and significant reductions in MRSA and C. difficile infections brought about by the hard work of NHS staff.

'As the BDA is aware, we have already committed to publishing the list of references for all our latest evidence at the earliest opportunity.'

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Absolutely farcical. Where are all these patients who must presumably be 'dropping like flies' at the present? Nowhere. They don't exist. Another army of jobsworths will be created to enforce this nonsense, and where exactly will the funding come from? Yup, the patients and the taxpayers (who must be feeling flush following the bank bailouts etc, etc). At the meeting I attended, it was clear there was almost no evidence base for any of it. Someone asked a question about why pubs/restaurants don't have vacuum autoclaves for their cutlery and glasses. The answer? 'You shouldn't behave like them, as you are professionals'. Marvellous. Hope the pathogens can spot the difference. The real answer, IMHO, the politicians are a lot more worried about Gordon Ramsay, Jamie Oliver et al slagging them off on the TV than they are concerned about patient safety or the viability of dental practices.
Cameron needs to immediately take a great big axe to the self-perpetuating QUANGO rain-forest as one of his first actions to save public money.

Posted by drstephenmorris 18/11/09 at 14:39

Where are the 60 references, Mr Cockroft?

Posted by jamesmehta 20/11/09 at 13:32

Is it suggested that patients must first 'drop like flies' before any kind of prevention is enforced? I understand the need for evidence and discussion on funding but not the outrage at guidelines that may protect the public. I also agree that possibly more needs to be done in other areas that are highly populated with the 'general public', in regard to hygiene and cleanliness. Maybe consider what standards you would wish upon your own friends and family..?

Posted by lilpinkmiss 4/1/10 at 12:20

lilpinkmiss - are you perchance from the USA? I believe they don't 'do' irony. The point is (obviously!) that there is no evidence whatsoever that current standards within general dental practices are not adequate. BTW, like most GDP's I TREAT all my friends and family. Otherwise, they'd have to pay......

Posted by drstephenmorris 5/1/10 at 22:46

Stephen- I am not from the USA, you are clearly a very angry person. If you have read articles (in Britain) you will see that there have been cases (in dentistry) that have arisen, in some cases very serious. Do you treat your friends and family for them to save money or to give you peace of mind that you personally can oversee the decontamination practices carried out..? I do see that there is cost involved, which may partly explain your upset, and there are certain things that need to be clarified, but I also believe in progress

Posted by lilpinkmiss 13/1/10 at 10:45

Me, angry?! Have you ever visited any political blogs? Don't - some of those folk really are angry.......
Anyway, cross-infection control is (blindingly obviously) taken very seriously in our practice. As to 'clarity' - as one eg the guidelines are (already) being amended re storage times for sterilised packaged instruments. As to expense, ultimately as a private practice it's the patients who pay, not us. I'd like to think family and friends see me as I am such a brilliant dentist :-) I read a lot of articles, but can't remember any recent egs in UK where 'very serious' harm has come to a patient in GD practice via cross-infection. Why don't you give us all some references (no scare-stories where PCT's have decidedt o ruin some poor GDP's life by writing to their pt's as a result of a positive HIV test please. I mean real, proven cases of actual patients getting communicable disease from their GDP carrying out dentistry, of course!). I believe in progress as well, but progress can only occur when there is evidence that what is currently practiced is inadequate. That's what evidence based dentistry is all about. Dr Cockcrofts' refusal to involve NICE in reviewing the new guidelines says it all - he's worried they might be independent enough to say lots of them are unneccessary.

Posted by drstephenmorris 13/1/10 at 15:03

I fully agree with you Dr Morris. Where is the scientific Evidence for it?

Posted by Frasse 13/1/10 at 17:18

I fully agree with both of you, we need evidence. I suggest Dr Morris has taken a disliking to me for questioning his opinions. I do not think that PCTs are trying to bully GDP's. Current practice may not be inadequate in Dr. Morris's particular surgery, but who's to say in other practices (without guidelines) that this is the case?

Posted by lilpinkmiss 18/1/10 at 12:02

In view of the latest exchanges between the BDA, NICE and the DH I have an appeal for reason.

I work in a special care dental clinic for a PCT and I find the uniform and workwear policy overbearing and ambiguous, particularly in relation to HTM 01-05.
Scientists suggest that there is nothing to worry about regarding contamination on uniforms but we are required to launder at 60 deg C for 10 minutes when our washing machines lack timers, despite the fact that a 30 deg C wash with a suitable detergent kills MRSA. Should we not be saving energy wherever possible?

The rigorous rules imply that there is a risk to health if they are not followed, so is it right to take uniforms home to launder? Those who do our laundry are not trained in the processing of potentially contaminated clothing. Hospital scrubs are not allowed to be taken out of hospital premises, and outpatient dental procedures are similar to clinic procedures.

I have asked NICE for their opinion on this. I was told that there are no guidelines. How strange. Either the issue is not sufficiently important or the Dh does not want HTM 01-05 scrutinised by NICE. I suspect that the huge burden borne by the dental profession as a result of this document may not have been absolutely necessary. I wonder why the DH do not want the evidence base of their work questioned?

Posted by tony5112 19/1/10 at 17:10

lilpinkmiss - why would you possibly think that I 'don't like you'? I would only gently suggest that you don't take message boards, blogs and so on personally. Some of the political blogs, for example, where I 'joust' , regularly 'flame' posters......but rarely does anyone feel that others dislike them. We should be lambasting Dr Cockcroft for refusing to allow independent scrutiny of the evidence base for HTM 01-05 by NICE. This refusal indicates a clear lack of confidence in the whole foundation for this policy. I believe it is merely a further symptom of the 'elfin safety/compensation culture' infesting this country, in other words the whole charade is just a huge CYA (cover your bottom) exercise by the DoH in case an episode ever does occur. Tony5112 - indeed. We probably will be ordered to install a laundry, all of course with verifiable printouts, logs, etc etc - maybe next to our burgeoning CSSD. Maybe the extra staff could do a bit of ironing between filing said printouts and so on?!

Posted by drstephenmorris 19/1/10 at 22:15

don't worry lilpinkmiss, you're not the problem, in fact I like that you've voiced an opinion that shows you actually care. drstephenmorris also cares (even though his patients are the ones paying) enough to fight the corner of a profession that should know better! I think we can safely say that the only thing 'not liked' here is the complete lack of commonsense demonstrated in the world today - in particular for us, by the regulators of dentistry today. The truth is that the public do expect different standards from us than they do from a restaurant. However, just a request (and this is genuine) could lilpinkmiss please point me in the direction of the articles about 'serious cases' in Britain that the change in regulations will address, i.e. that haven't been addressed by existing regulation?

Posted by bertiesmile19 22/1/10 at 23:41

We wish someone would hurry up and make a descision, as suppliers have just as hard a time trying to offer the correct solution for practitioners in the first place !!

Posted by blueprintdental 26/1/10 at 21:33

blueprintdental - now, you're absolutely dead sure, here, I hope that the suppliers are never ever going to be doing any 'pushing' to get loads of superfluous but really really expensive kit (which constantly breaks down, thus needing a really, really expensive maintenance contract) compulsorially fitted into loads of practices? Glad to hear it, as that wouldn't ever be how those selfless, charitable equipment suppliers have behaved in the past.

Posted by drstephenmorris 27/1/10 at 00:10

when some practices are re-using tee-pee brushes on patients and using water from an outside water butt - believing it is sterile water then yes I do believe the standards need to be changed!

Posted by candy656 10/2/10 at 00:29

listen candy mate if thats the practice ur working at then leave

Posted by steve 10/2/10 at 22:00

Candy, I would only add to Steve's comment - after you have left, write an appropriate letter to GDC, PCT and so on. Use Registered Post, keep copies. Changing standards isn't going to stop criminals, only brave and determined whistleblowers can possibly protect patients from such charlatans.

Posted by drstephenmorris 10/2/10 at 23:43

I do not work at these practices - but these are just a number of infection control blunders - i know another practice puts all his gloves in the washing machine to cut costs.. what else do we not know about!

Posted by candy656 11/2/10 at 09:59

Candy656 - IMHO you have a duty to report these criminals to the authorities. I say again, 'standards' won't stop such crooks. Being 'had up', as in court, GDC, service committee and then a nice piece in the local papers might concentrate their minds.

Posted by drstephenmorris 11/2/10 at 15:24