An Audit of Cross Infection Control

Procedures in General Dental Practice

Project Coordinator: Dr John Booth, GDP

August 1999

The Primary Care Clinical Audit TeamPrimary Care Development

Stevenson House555 Gorgie Road

Edinburgh EH11 3LGTel: 0131 537 8562 Fax: 0131 537 8502

Contents

Abstract 1

Introduction 2

Aims 3

Methodology 3

Results 4Personal Details 4Personal Protection 5Cleaning & Sterilisation of Instruments 10Cleaning & Disinfecting Surfaces 13Clinical Waste Disposal 17General Comments 20

Discussion 21

Recommendations 23

Acknowledgements 24

References 25

Abstract

This audit aimed to establish the cross infection control procedures currently being carried out within Lothian general dental practices related to the BDA guidelines issued in Advice Sheet A12. Nurses and general practitioners in participating practices were asked to complete confidential questionnaires based around a core of the BDA guidelines. The response rate was 43%. The results show that most dentists and nurses follow most of the recommended guidelines most of the time. However, cross infection control could be further improved by some simple measures e.g. reviewing the use of protective eyewear for all team members and patients during aerosol-producing procedures. The audit also highlighted the need for standardised guidelines and emphasised the need for such guidelines to be adopted and “owned” by the chairside team as a whole. 41.6% of dentists and 20% of nurses identified the need for further training and 21.5% of dentists and nurses indicated that revision of the guidelines would reduce difficulties in applying recommended guidelines in the surgery.

Introduction

The importance of protecting patients and staff from cross infection within the dental practice should be obvious to all members of the dental team. The last decade has seen cross infection control guidelines change in response to our increased knowledge of

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potential pathogens and their routes of transmission. Current recommendations indicate that we should take “universal precautions” so that all of our patients are treated in the same way under the assumption that any patient could be a source of infection and conversely that we have the potential to infect any of our patients. Consequently, such guidelines need to be reviewed regularly so that the dental team and the cross infection control procedures that they practice are kept up to date.

This audit was devised to assess those cross infection control procedures currently being carried out routinely in dental practices within Lothian. However, it was also hoped that participation in the audit would prove useful to individual practices by leading the dental team to scrutinise their own cross infection control procedures.

The questionnaire was compiled using the BDA guidelines on cross infection control1 as a benchmark but rather than produce questions covering every aspect of those guidelines, focussed on the main areas covered within each section. It was hoped that a more user-friendly document might then be produced which would in turn lead to a higher response rate from individual practices.

In most practices many cross infection control procedures are delegated to the dental nurse and so, given this team approach, a questionnaire was sent to both dentist and nurse individually. In this way it was hoped to gain a greater insight into any differences which might exist between different members of the chairside team. Again, this would allow practices greater scope for scrutinising their own procedures.

In a similar vein the questionnaire asked respondents for some personal details to attempt to determine any correlation between these and the procedures being carried out. Where significant correlations did occur, these have been detailed, where appropriate, within the results section.

Unfortunately, the response rate to the questionnaire was low but the results do provide an overview of the cross infection control procedures currently being carried out within general dental practices in Lothian and will I hope prove useful to all of those who took part in the audit.

Aims

To assess cross infection control procedures of general dental practitioners and dental nurses in Lothian.

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The British Dental Association Advice Sheet on Infection Control in Dentistry1 was used as a standard against which to compare practice.

Methodology

A confidential coded questionnaire was sent to all general dental practitioners in Lothian and the dental nurse who worked most closely with them. Both the general dental practitioner and dental nurse were provided with their own return envelope in the hope that this would encourage dental nurses to provide more open responses. The questionnaire was based on the British Dental Association Advice Sheet and consisted of 6 categories: personal details, personal protection, cleaning and sterilisation of instruments, cleaning and disinfecting surfaces, clinical waste disposal and general comments.

Statistical analysis was undertaken using SPSS. Each variable was analysed for each group and differences between the groups were investigated using Pearson’s Chi squared test. Data from the Personal Details section was cross-referenced to cross infection control practice to establish if this had any effect.

Results

Of the 756 questionnaires sent out, 10 were non-deliverable and 279 (149 dentists and 130 nurses) were returned, a response rate of 37.4%.

Questionnaires were sent to all general dental practitioners and their dental nurses at all practices in Lothian, however, a number of dentists work at more than one practice and so

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received 2 questionnaires but only completed and returned one. If this is taken into account then the response rate is 43%.

Personal Details

81.9% of dentists had graduated more than 5 years ago, 51.7% were the practice owner and 63.1% had worked in their current practice for more than 5 years.

63.1% of nurses had been a dental nurse for more than 5 years, 66.9% were qualified nurses and 44.6% had worked in their current practice for more than 5 years.

Review of BDA Advice Sheet

Figure 1: Review of BDA Advice Sheet

CommentsA high percentage of dentists and nurses had never reviewed the BDA guidelines. However, it would be hoped that this group has reviewed an alternative source of Cross Infection Control Guidelines such as S.A.M.S. If not, then a review of the guidelines would certainly be strongly recommended now.

This is of particular importance since studies2 have shown that dentists and nurses who keep their knowledge up to date were much more likely to follow recommended guidelines.

Personal Protection

Criteria

The BDA Advice Sheet states that:

“It is imperative that all staff are vaccinated against the common illnesses.

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31.5 29.2

13.422.1

29.5

7.7

20

35.4

0

20

40

60

80

100

within last

year

within last

1-2 years

over 2

years ago

never

perc

en

tag

e

Dentist

Nurse

Good quality non-sterile medical gloves should be worn for all clinical procedures and changed after every patient.

Masks or visors are recommended for all operative procedures.(for both dentists and nurses)

Patients’ eyes must always be protected against possible injury.”

Findings of Lothian Audit

A higher proportion of dentists were vaccinated against TB, 82.6%, compared to 71.5% of nurses (p=0.028). Only 59.1% of dentists were vaccinated against rubella compared to 81.5% of nurses (p=0.000).

Figure 2: Vaccination status

CommentsAlmost all respondents had been vaccinated against Hepatitis B, which would be expected given that Lothian Health Board have been operating a very successful vaccination programme in dental practices for some time now.

It is hoped that the small percentage of respondents who had not been vaccinated (who presumably may be new members of the dental team) will be soon.

A large number of respondents had not been vaccinated against TB. As vaccination is usually carried out on schoolchildren it is possible that some respondents may not have realised or have forgotten what they have been vaccinated against, whilst, others may not have required vaccination at the time. Although TB is largely regarded as having been conquered in most developed countries cases are on the rise in Eastern Europe and the developing world whilst drug resistant strains are also becoming more prevalent. It is therefore important for dentists and nurses to clarify their own TB status.

Similarly a large number of respondents had not been vaccinated against rubella with a significant difference between dentists and nurses. It may be surmised that fewer dentists have been vaccinated, as there will be many more male respondents in this group than there are amongst the nurses. School rubella vaccination programmes are primarily aimed at females and this probably accounts for the significant difference between the groups. However, Lothian Health Board has recommended in the past that male dentists

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98.7

82.6

59.1

97.7

71.5

81.5

0

20

40

60

80

100

Hepatitis Tuberculosis Rubella

perc

en

tag

e

Dentist

Nurse

and nurses should consider being vaccinated against rubella to break the chain of infection. Males may act as a reservoir for rubella infection which may be passed on to those females in the general population who have not yet been, or cannot be vaccinated against rubella.

Individual dentists and nurses should therefore review their vaccination status in light of this information.

96.6% of dentists and 88.5% of nurses always wore gloves when treating patients (p=0.049).

Figure 3: Gloves worn when treating patients

72.5% of dentists and 70.8% of nurses always wore a new pair of gloves for each patient being treated.

Figure 4: New Gloves are worn for each patient32.2% of dentists and 33.1% of nurses always washed/disinfected their gloves between each patient.

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0.83.4

96.6

1.59.2

88.5

0

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

2.32

25.5

72.5

3.1

23.8

70.8

0

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

Figure 5: Gloves washed between each patient

The guidelines state that a new pair of gloves should always be worn for each patient. Washing gloves between each patient is no longer regarded as satisfactory. Figure 5 highlights a “discrepancy” in the results as 72.5% of dentists and 70.8% of nurses always wore new gloves for each patient being treated, yet, 42.9% of dentists and 39.3% of nurses always or sometimes washed gloves between patients.

93.3% of dentists and 94.6% of nurses always discarded and replaced torn, cut or punctured gloves immediately.

Figure 6: Torn, cut or punctured gloves were immediately discarded and replaced

When cross-referenced with Personal Details it was found that graduation of less than 5 years ago (p=0.011), not being a practice owner (p=0.009) and having been employed for less than 5 years (p=0.007) all had an effect on glove wearing practice in that these dentists were more likely to always wear a new pair of gloves for each patient.

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14.1 12.3

32.2

10.7

43

33.1

6.2

48.5

0

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

0.7 1.5

93.3

6

94.6

2.3 1.50

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

64.4% of dentists and 60.8% of nurses always wore surgical-type masks whilst carrying out any procedure which might have involved a risk of splash or aerosol generation.

Figure 7: Surgical-type masks were worn

Of those nurses who responded to this question (n=128), 67.8% of qualified nurses always wore a mask compared to 48.8% of unqualified nurses (p=0.024).

81.9% of dentists and 60.8% of nurses always wore eye protection whilst carrying out any procedure which might have involved a risk of splash or aerosol generation (p=0.001).

Figure 8: Eye protection was worn

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0.8

64.4

24.8

10.7

60.8

23.115.4

0

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

0.8

81.9

12.16

60.8

21.516.9

0

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

56.4% of dentists and 56.9% of nurses always provided eye protection for patients whilst carrying out procedures which might have involved a risk of splash or aerosol generation.

Figure 9: Eye protection provided for patients

CommentsA large number of respondents only wore masks sometimes or not at all. Whilst nurses and patients used eye protection far less frequently than dentists despite being just as vulnerable to eye contamination or injury during splash producing procedures.

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0.8

56.4

32.2

11.4

56.9

26.9

15.4

0

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

Cleaning and Sterilisation of Instruments

Criteria

The BDA Advice Sheet states that:

“It is recommended that all instruments contaminated with oral and other body fluids are sterilised. There are three stages to the sterilisation process: pre-sterilisation cleaning, sterilisation and aseptic storage.

(i) Pre-sterilisation cleaning: Used instruments are often contaminated with blood and saliva and must be completely cleaned, by hand or using an ultrasonic bath before sterilisation.

It is important that thick household-type gloves are worn when cleaning instruments to protect against accidental injury….

(ii) The method of choice for the sterilisation of all dental instruments is autoclaving.”(all that are autoclavable)

Findings of Lothian Audit

19.5% of dentists and 26.2% of nurses reported that thick gloves were always worn when cleaning used instruments by hand.

Figure 10: Thick gloves were worn when cleaning used instruments

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2.7 1.5

19.5

31.5

46.3

26.2 23.8

48.5

0

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

67.1% of dentists and 80.8% of nurses reported that manual scrubbing was always used to clean handpieces before sterilisation (p=0.035).

Figure 11: Manual scrubbing used to clean instruments before sterilisation

Figure 12: Ultrasonic bath used to clean instruments before sterilisation

CommentsA large number of respondents indicated that thick gloves were only used sometimes or never when cleaning used hand instruments. Yet, this appeared to be the preferred method of cleaning before sterilisation for most respondents and not the use of ultrasonic baths. Therefore, the increased use of thick protective gloves would be very desirable.

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32.317.4

25.4

26.2

18.811.7

43 36.243.6

38.5

47 43.1

24.231.5 26.8

30.228.5

25.5

0%

20%

40%

60%

80%

100%

Den

tist

Nu

rse

Den

tist

Nu

rse

Den

tist

Nu

rse

perc

en

tag

e

Missing

Never

Sometimes

Always

Hand instruments Burs 3-in-1 Tips

68.55780.867.184.679.789.285.9

9.44.68.7 6.2

21.5

9.2

9.4

6.2

0%

20%

40%

60%

80%

100%D

enti

st

Nurs

e

Denti

st

Nurs

e

Denti

st

Nurs

e

Denti

st

Nurs

e

perc

enta

ge

Missing

Never

Sometimes

Always

Hand instruments Burs 3-in-1 TipsHandpieces

When cross referenced against personal details it was found that those who had been a nurse for more than 5 years were more likely to always manually scrub handpieces before sterilisation, 87.8% compared to 68.8 % of nurses with less than 5 years experience (p=0.022). However, the results also showed that unqualified nurses were more likely to always manually scrub handpieces before sterilisation 95% compared to 76.7% of qualified nurses (p=0.042).

Initially it was thought that this difference could be explained by the fact that nurses with greater than 5 years experience were more likely to be unqualified compared to nurses with less than 5 years experience, however, the data did not support this. It is therefore not possible to explain this difference from the data available.

Figure 13: Method of sterilising instruments

CommentsThe information regarding the cleaning and sterilisation of 3-in-1 tips should be viewed in light of the fact that a number of practices used disposable tips.

All hand instruments and handpieces were sterilised using an autoclave but a large number of respondents used disinfectant to “sterilise” burs. This can no longer be regarded as a sure method of sterilisation of burs given the length of time that they must be immersed in such solutions for sterilisation to occur.

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Cleaning and Disinfecting Surfaces

Criteria

BDA Advice Sheet A12 states that:

“Effective cleaning and disinfecting are greatly aided and simplified by a strict system of zoning. In practice, this means defining the areas which may be contaminated during the operative procedures; only these areas need to be cleaned and disinfected between patients.

Protect light and chair controls (which are likely to be contaminated) with disposable impervious coverings and change between patients. If disposable coverings are not used the controls must be effectively decontaminated between patients.

All aspirators, drains and spittoons should be cleaned after every session with a non-foaming disinfectant.

Impressions and prosthetic and orthodontic appliances must be carefully cleaned and disinfected before they are sent to a laboratory.” (While laboratory constructed impression trays, bite blocks and appliances should be disinfected when they are returned from a laboratory)

Findings of Lothian Audit

57.7% of dentists and 73.8% of nurses reported that work surfaces were always separated and zoned into “clean” and “contaminated” (p=0.037).

Figure 14: Work surfaces were zoned

CommentsFewer dentists reported that areas were zoned within the surgery whereas more nurses reported that zoning was carried out. This may highlight an area where better communication within the surgery would further improve the team approach to good cross infection control.

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3.4 2.3

57.7

19.5 19.5

73.8

13.8 10

0

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

92.6% of dentists and 93.8% of nurses reported that contaminated work surfaces were cleaned and disinfected after each patient.

Figure 15: Contaminated work surfaces were cleaned and disinfected

Figure 16: Covering/disinfecting of the chair, equipment handles and switches

Of those nurses who responded to this question (n=107), qualified nurses were more likely to wipe down equipment at the end of the session, 97.1%, compared with 83.8% of unqualified nurses (p=0.03).

CommentsThe use of disposable covers did not appear to be a popular method of cross-infection control. It may be that time (and perhaps financial) factors heavily influence decisions on the use of such covers.

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92.6

7.4

93.8

6.2

0

20

40

60

80

100

Always Sometimes Never

perc

en

tag

e

Dentist

Nurse

76.2 78.5 76.9

18.5

72.5 58.5

2.7 6.9

66.4

4.68.7

16.1 15.4

29.5

0%

20%

40%

60%

80%

100%

Denti

st

Nurs

e

Denti

st

Nurs

e

Denti

st

Nurs

e

perc

en

tag

e

Missing

Never

Sometimes

Always

Covered Wiped af ter

each patient

Wiped at end

of session

91.9% of dentists and 91.5% of nurses reported that a tray system was always used to deliver instruments to the dental unit.

Figure 17: A tray system was used

Only 19.5% of dentists and 15.4% of nurses reported that disinfectant was always flushed through the aspirators and spittoons after each treatment session, and 88.6% of dentists and 89.2% always did so at the end of the day.

Figure 18: Flushing of disinfectant through aspirators and spittoons

Length of service appeared to have some effect on nurses’ practice. Of the nurses who responded to this question (n=105), those with less than 5 years experience were more likely to never flush disinfectant through aspirators and spittoons at the end of each session, 30%, compared to 9.2% of nurses with more than 5 years experience (p=0.017).

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0.7 0.8

91.9

4.7 2.7

91.5

3.8 3.80

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

89.2

18.8 13.8

19.5 15.4

88.6

6.9

46.3 51.5

6.7

0%

20%

40%

60%

80%

100%

Dentist Nurse Dentist Nurse

perc

en

tag

e

Missing

Never

Sometimes

Always

Af ter each

treatment sessionAt the end

of the day

Only 53% of dentists and 59.2% of nurses reported that impressions and appliances were always cleaned and disinfected before being sent to the laboratory.

It is worth noting that some respondents said that they cleaned but did not disinfect impressions and appliances.

Figure 19: Impressions and appliances were cleaned and disinfected

CommentsMany dental labs will disinfect incoming impressions etc and will also disinfect outgoing work. However, the onus is on individual dental practices to protect their own patients whilst also protecting staff in dental labs, therefore, it would seem prudent to focus more attention on this area of cross infection control. Some respondents replied that there was some confusion regarding methods of disinfection of impressions and certainly there were difficulties in doing so. The BDA has published a useful helpsheet on this topic, a summary of which is included with this document.

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2 5.4

53

34.2

10.7

59.2

22.313.1

0

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

Clinical Waste Disposal

Criteria

The BDA Advice Sheet states that:

“All waste in the practice should be segregated into clinical and non-clinical waste. Waste contaminated with blood, saliva or other body fluids is regarded as clinical waste and must be stored in yellow containers (sacks).

Sharps (needles, scalpel blades, used local anaesthetic cartridges etc.) must be sealed in rigid puncture-proof containers before disposal.

Clinical waste must only be collected for disposal by a registered waste carrier.”

Findings of Lothian Audit

91.9% of dentists and 91.5% of nurses stated that waste was always separated into clinical and non-clinical waste.

Figure 20: Waste separated into clinical and non-clinical

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0.8

91.9

5.4 2.7

91.5

5.4 2.30

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

99.3% of dentists and 99.2% of nurses stated that used sharps were always disposed of in a rigid sealable container.

Figure 21: Used sharps disposed of in a rigid container

94% of dentists and 94.6% of nurses reported that all other clinical waste was always stored in yellow sacks.

Figure 22: All other clinical waste stored in yellow sacks

98.7% of dentists and 97.7 % of nurses reported that used sharps and other clinical waste was always collected separately from general refuse.

Figure 23: Used sharps and clinical waste collected separately from general refuse

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0.8

99.3

0.7

99.2

0

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

0.8

94

4 2

94.6

3.8 0.80

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

0.8

98.7

0.7 0.7

97.7

0.8 0.80

20

40

60

80

100

Always Sometimes Never Missing

perc

en

tag

e

Dentist

Nurse

When cross-referenced against personal details it was found that practice owners were more likely to always store clinical waste in yellow sacks, 98.7% compared with 88.9% of non-practice owners (p=0.038).

CommentsConcern must be raised that small numbers of respondents replied that used sharps were only disposed of in a rigid container sometimes, that other clinical waste was only stored in yellow sacks sometimes or never and that used sharps and clinical waste were not collected separately from general refuse.

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General Comments

36.5% of dentists and 20.2% of nurses reported that they had difficulty in following recommended cross infection control procedures (p=0.003).

Nurses predominantly cited time constraints as the reason for this. This was also most commonly cited by dentists followed by financial constraints.Figure 24: Reasons for difficulties in following procedures

When asked what factors would assist in reducing difficulties in applying recommended procedures 41.6% of dentists said further training for the chairside team and 21.5% of nurses said revised guidelines for cross infection procedures.

Figure 25: Factors which would reduce difficulties

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10.84.6

28.9

14.14.7

18.5

1.5 1.50

20

40

60

80

100

Time

constraints

Financial

contraints

Lack of

relevance

Other

perc

en

tag

e

Dentist

Nurse

41.6

21.516.820 21.5

13.1

0

20

40

60

80

100

Further

training

Revised

guidelines

Other

perc

en

tag

e

Dentist

Nurse

Discussion

Analysis of the completed questionnaires has thrown up some significant points which have been highlighted where appropriate in the results section. However, it would be useful to discuss some of these points further.

Firstly, there were significant differences in personal protection between dentists and nurses. Dentists were more likely to wear gloves and protective eyewear when carrying out treatment than were nurses. Whilst, most nurses cleaned “used” instruments by hand rather than using an ultrasonic bath, relatively few wore thick gloves while doing so. Other studies2 show that these differences are not confined to Lothian and that there is in general much greater scope for improvements in personal protection for dental nurses than for dentists. Evidence has shown that dental nurse behaviour is related to that of the dentists they work with3. It would therefore seem desirable for both dentists and nurses to look at this aspect of cross infection control together.

When responses from qualified and unqualified nurses were compared there was a significant difference between the two groups: qualified nurses were more likely to wear a mask and wipe down equipment at the end of the session. Significant differences were also recorded between nurses with over five years experience and those with less experience: nurses with over five years experience were more likely to scrub handpieces before sterilisation and flush disinfectant through aspirators and spittoons at the end of each session than were less experienced nurses.

This suggests that qualified and experienced nurses are more likely to follow guidelines in general as has been shown in other studies4. Once again this points to the standard of cross infection control being improved by increased or better training.

Similarly it was found that younger dentists who were not a practice owner were more likely to wear new gloves for every patient than were their older colleagues or practice owners. This might imply that more recent graduates are more up to date with cross infection control procedures which has again been shown in other studies 3.

It is well known that knowledge, unless reinforced5, decreases with time. In light of this and changing cross infection control guidelines it would seem highly desirable to regularly audit and update individual practice cross infection control procedures. Communication between dentist and nurse must be effective so that each understands their respective role and can carry out good cross infection control as a team. Similarly knowledge must be updated by reviewing guidelines regularly and through further training.

However, it has been suggested by Hudson-Davies, Jones and Sarll3, that “present methods of updating education and training are largely ineffective as a way of improving cross-infection control procedures”. While they quote from another field, Sir John Harvey Jones6, who notes “it is extremely difficulty to teach grown up people anything (but)... relatively easy to create conditions under which people will teach themselves....” He continues “.... most people wish to improve their own performance and are eager to do so”.

If we assume that respondents in this audit are interested in cross infection control, and

27/09/99 21

relate the numbers of respondents who indicated that further training or revised guidelines would be useful, then there would seem to be a large number of dentists and nurses who are keen to improve their practice of cross infection control.

It would also seem that further training would be most effective if it were based around the dental team as a whole rather than handed down from only one of its members. This would enable team members to teach themselves and to develop their “own” guidelines to cross infection control.

Recommendations

27/09/99 22

Practices should update their knowledge by regularly reviewing guidelines on cross infection control.

Individual dentists and nurses should review their vaccination status.

An ultrasonic bath is the favoured method of pre-sterilisation cleaning but when one is not used the wearing of thick protective gloves when cleaning instruments is recommended.

Both dentists and nurses should examine their wearing of gloves, masks and eye protection and should provide suitable eye protection for their patients.

Better communication regarding the zoning of work surfaces would further improve the team approach to good cross infection control.

Practices should refer to the fact sheet regarding the disinfection of items being sent to and received from dental laboratories.

All practices should adhere to the guidelines regarding the disposal of clinical waste.

Further training would be most effective if it were based around the dental team.

Acknowledgements

27/09/99 23

I am indebted to Elaine Wilson of the Clinical Audit Team for her invaluable assistance throughout the audit and to all of the dentists and nurses who took the time to participate. I would also like to thank Terry Simpson for his helpful advice and comments and to acknowledge the assistance of the BDA Advisory Service in allowing reproduction of the Cross Infection Control Checklist and the factsheet on the Disinfection of Impressions.

References

1 British Dental Association Advice Sheet A12 on Infection Control in Dentistry, 1996

27/09/99 24

2 Bentley EM, Sarll DW. Improvements in cross-infection control in general dental practice. Br Dent J 1995; 179:19-21

3 Hudson-Davies SCM, Jones JH, Sarll DW. Cross-infection control in general dental practice:dentists’ behaviour compared with their knowledge and opinions. Br Dent J 1995;178:365-369

4 Banks T, Jones JH, Saril DW. Dental surgery assistants’ roles in cross-infection control in general dental practice: their knowledge and use of autoclaves. Br Dent J 1994;177:378-381

5 Kunzel C, Sadowsky D. Knowledge acquisition processes: dissemination of expert recommendations to general practice dentists. J Health Social Behav 1989; 30: 330-343

6 Harvey Jones, Sir John. Making it happen. London: Fontana, 1988

27/09/99 25

For further information or, copies of the report, please contact

Primary Care Clinical Audit TeamPrimary Care Development

Stevenson House555 Gorgie Road

Edinburgh EH11 3LGTel: 0131 537 8562 Fax: 0131 537 8502