Contaminated bracket

The scene

While preparing to fit brackets for an orthodontic patient, a practice principal was shocked to find that among the brackets he selected from the plastic storage box was one which was caked in debris and cement. It had obviously been used before. He immediately discarded the bracket and the others from the same well of the box.

Puzzled as to how this could have happened, he spoke to a colleague after the consultation and was alarmed to find that the colleague had very recently experienced a similar incident. When they examined all the brackets in their stocks, they found a further three that were contaminated.

Both dentists believed the chance of a contaminated bracket ending up in the storage boxes was minuscule and were baffled as to how it might have happened. Normally, their practice was to only reuse brackets when a patient presented with a loose one, in which case they would personally remove and sandblast it before handing it to the nurse to place the cement and then immediately fitting it.

Concerned at the obvious breach of infection control and the potential consequences for patients and the practice, the principal rang the DDU for advice.

DDU advice

Hygiene has always been a priority in dental practice, but in recent years there has been an increasing emphasis on infection control. It goes without saying that all dental professionals are expected to meet stringent standards, and the DDU adviser cautioned that failure to enforce adequate infection control procedures could lead to sanctions being imposed on the practice by the regulators.

In the DDU's experience, one of the most common allegations made by patients about lapses in infection control relates to unsterilised instruments. However, it would be highly unusual, the adviser said, to find contaminated brackets among stores ready for use on patients. Most often, such incidents arise from human error or a misunderstanding of infection control procedures. In that case, an appropriate course of action would be to review the practice infection control policy, changing or updating it as necessary, and undertake staff training in the principles and practice of infection control.

Breaches of infection control may have serious consequences. First, there is the potential to compromise patients' health. If, following the initial investigation, the principal thought there was any possibility that the breaches in infection control could have consequences for a patient, he was advised to consider contacting the local public health team for further advice on whether the practice should carry out a patient notification exercise. Second, the regulators can impose sanctions on practices or individual dental professionals for substandard procedures.

In England, the standards are set out in the Department of Health's Decontamination in primary care dental practices (2013), which gives benchmarks for both quality requirements and best practice. Similarly, outcome 8 of the Care Quality Commission (CQC) essential standards, which concerns cleanliness and infection control, establishes what is expected of all practices. The CQC can cancel a practice's registration if it finds infection control falls below what is required. The GDC is likely to be notified if the CQC imposes sanctions on a practice.

In Scotland, guidance on infection control can be found in Contamination into practice, published by the Scottish Dental Clinical Effectiveness Programme (SDCEP). All NHS practices that provide general dental services were required to be compliant with SDCEP standards by the end of 2012. Local health boards now carry out inspections every three years and practices which do not pass will lose their entitlement to the general dental practice allowance and reimbursement of practice rental costs.

Standards in Northern Ireland are set by the Department of Health, Social Services and Public Safety. Practices are subject to inspection by the Regulation and Quality Improvement Authority against Department of Health best practice benchmarks.

Dental practices in Wales are also subject to the Department of Health's essential requirements and best practice. Local Health Boards are responsible for ensuring that standards are met and routine inspections are carried out by the Dental Reference Service every three years.

Leo Briggs
Dento-legal adviser

This page was correct at publication on 04/12/2013. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.