Assessing Your Dental Services for Compliance – Part II

In Part 1 of our series on Dental Services, we discussed administrative responsibilities, education and training, personnel safety, hand hygiene, personal protective equipment, sharps safety, safe injection practices, sterilization/disinfection of patient care devices, and environmental infection prevention and control. Now that the basics have been discussed let us dig our teeth into some dental service specifics!

This article will discuss Water Quality, Amalgam, Imaging Safety, Emergency Care Needs Management, Invasive Procedure Consents, Assessment, and Discharge Instructions.

Dental Unit Water Quality

Biofilm can place both healthcare professionals and patients at risk of adverse health effects if water is not appropriately treated.  Biofilm is a thin slimy film of bacteria that sticks to moist surfaces, such as those inside dental unit waterlines. Biofilm occurs in dental unit waterlines because of the long, small-diameter tubing and low flow rates used in dentistry, the frequent periods of stagnation, and the potential for retraction of oral fluids. High numbers of common water bacteria can be found in untreated dental unit water systems. Disease-causing microorganisms found in untreated dental unit water include Legionella, Pseudomonas aeruginosa, and nontuberculous Mycobacteria.

To avoid water quality issues, the following are advised:

  • Use water that meets EPA regulatory standards for drinking water (i.e., ≤ 500 CFU/mL of heterotrophic water bacteria) for routine dental treatment output water.
  • Consult with the dental unit manufacturer for appropriate methods and equipment to maintain the quality of dental water.
  • Follow recommendations for monitoring water quality provided by the manufacturer of the unit or waterline treatment product.
  • Use sterile saline or sterile water as a coolant/irrigant when performing surgical procedures.

Monitoring dental unit water quality can help identify problems in performance or adherence with maintenance protocols and provide documentation of compliance. Follow recommendations for monitoring water quality provided by the manufacturer of the unit or waterline treatment product. Commercial self-contained test kits or water-testing laboratories are available for this purpose.

If water testing results exceed the CDC recommended limit of ≤500 CFU/mL of heterotrophic water bacteria, the unit should be treated according to manufacturer IFU, and re-tested immediately after treatment. If a unit remains resistant to treatment over time, it may be necessary to replace waterlines or other water-bearing components.


Regulatory agencies are reaching out to the dental community to encourage the reduction of amalgam and mercury in the waste stream. Amalgam waste is easily captured and can be recycled. Recycling is the preferred method of managing this waste.

  • Do not rinse amalgam-containing traps, filters, or containers in the sink.
  • Do not place amalgam, elemental mercury, broken or unusable amalgam capsules, extracted teeth with amalgam, or amalgam-containing traps and filters with medical “red-bag” waste or regular solid waste.
  • Recycle, or manage as hazardous waste, amalgam, elemental mercury, broken or unusable amalgam capsules, extracted teeth with amalgam, amalgam-containing waste from traps and filters. Empty dental amalgam capsules containing no visible materials, may be disposed of as a non-hazardous waste, except as required by local regulations.
  • Collect and store dry dental amalgam waste in a designated, airtight container. Amalgam, which is designated for recycling, should be labeled “Scrap Dental Amalgam” with the name, address and phone number of your office and the date on which you first started collecting material in the container. In the past, dental amalgam scrap may have been kept under photographic fixer, water or other liquid. If you should encounter amalgam stored in this manner, do not under any circumstances decant the liquid down the drain and discontinue this practice in the future.
  • Keep a log of your generation and disposal of scrap amalgam; inspectors may ask to see this to verify that your office is managing it correctly. A generation and disposal log is a record of what you placed in the amalgam container, when it was placed in the container and when the container was picked up by or sent to a recycler or hazardous waste hauler.
  • Check with your amalgam recycler for any additional requirements. Some recyclers do not accept contact amalgam (amalgam that has been in the patient’s mouth); others may require disinfecting the amalgam waste. All recyclers have very specific packaging requirements.
  • Separate excess contact dental amalgam from gauze that is retrieved during placement and place in an appropriate container.
  • Use chair-side traps to capture dental amalgam.
  • Change or clean chair side traps frequently. Flush the vacuum system before changing the chair-side trap.
  • Change vacuum pump filters and screens at least monthly or as directed by the manufacturer.
  • Check the p-trap under your sink for the presence of any amalgam-containing waste.
  • Eliminate all use of bulk elemental mercury and use only pre-capsulated dental amalgam for amalgam restorations.
  • Limit the amount of amalgam triturated to the closest amount necessary for the restoration, i.e. do not mix two spills when one spill would suffice. Keep a variety of amalgam capsule sizes on hand to ensure almost all triturated amalgam is used.
  • Train staff that handle or may handle mercury-containing material its proper use and disposal.
  • Install an amalgam separator compliant with ISO 11143.
  • Do not use bleach to clean discharge systems as this may mobilize legacy mercury and amalgam in the system.

Imaging Safety

The goal of dental radiation safety and protection is to obtain diagnostic dental images while keeping exposure to a minimum. ALARA (As Low As Reasonably Achievable) is the key. Essentially, ALARA involves using safety and protection practices when taking dental images. These practices will reduce unnecessary X-ray exposure to both patients and dental staff.  To protect your patients the following practices should be used to protect them from unnecessary X-ray exposure during dental imaging procedures:

  • Place a protective device on the patient.
  • Lead apron – In 2004, the National Council on Radiation Protection (NCRP) eliminated the requirement for the leaded apron because there is no scatter radiation below the neck of the patient provided all the recommendations of the NCRP Report are rigorously followed. These recommendations include using a long PID, rectangular collimation, and correct settings. However, many patients expect the apron and may even request one. Its use remains a prudent but not essential practice.
  • Thyroid collar - The thyroid is among the most radiation-sensitive tissues in the neck area. The thyroid helps control the body’s ability to change food into energy. Thyroid collars are recommended with the exception of panoramic imaging where the collar may interfere with the X-ray beam.
  • Folding an apron or thyroid collar will eventually result in the development of cracks in the protective lining. Cracks could allow radiation to reach the patient! Store your aprons and thyroid collars per the manufacturer’s instructions for use, clean them, and have them tested per your organization's policy and procedure.
  • Use rectangular collimation. Like the chest, abdomen, reproductive organs, and thyroid, the eyes are radiation sensitive. Protecting the patient’s eyes from radiation can be accomplished by using rectangular collimation. With rectangular collimation, radiation exposure to a patient is limited to the size of the receptor. This reduces the overall radiation exposure to a patient. The eyes and thyroid are also protected.
  • Use good techniques to reduce retakes. The general rule to remember is to make certain that the receptor and the positioning indicating device (PID or cone) are in the proper position before taking an exposure. The best way to avoid blurred images is to have both the X-ray head and the patient remain still during the time of exposure.

Remember, the three basic protective measures in radiation safety: time, distance, and shielding. Distance yourself appropriately from sources of radiation. Use appropriate shielding for the type of radiation. Contain radioactive materials within defined work areas. Wear appropriate protective clothing and dosimeters.

Emergency Care Management

The American Dental Association (ADA) defines dental emergencies as a collection of potentially life-threatening diagnoses requiring immediate treatment to stop bleeding, remedy the infection, and alleviate severe pain. However, not all dental emergencies put life in danger. The most common medical emergency in the dental office is syncope (more than 50%), followed by mild allergic reaction (8%), angina pectoris (8%), postural hypotension (8%), and seizures (5%).

Staff need to be trained to act in the event that one of these occurs. Policies, procedures, and/or protocols need to be developed, staff educated, trained, and finally have a competency performed to ensure that if an adverse event occurs they are able to act appropriately.

The six essential emergency medications that are recommended to have on hand are oxygen, epinephrine, nitroglycerine, antihistamine, albuterol, and aspirin.

  • Oxygen – used in almost any medical emergency
  • Epinephrine – for anaphylaxis, cardiac arrest
  • Nitroglycerine – angina pain
  • Antihistamine – allergic reaction
  • Albuterol – asthmatic bronchospasm
  • Aspirin – myocardial infarction

It is important to remember to call 911, as soon as possible, if the adverse event cannot be handled in the office or clinic.  Depending upon the adverse event instructions to visit one’s primary care physician my be advisable.

Invasive Procedure Consents

Complete information before an invasive procedure is an ethical requirement, and it is very important to involve the patient in decision-making regarding the treatment. Well-informed patients are generally more satisfied and file fewer legal claims. Informed consent requires a dentist to explain the likelihood of success of a given procedure and its risks, benefits, and alternatives. Included in that conversation should be an explanation of the treatment plan’s expected sequence of events.

A dentist, not a staff member, must lead this conversation. The amount of time spent discussing options and answering a patient's questions depends on the level of risk.


Along with a visual inspection of the mouth, the exam may also include a check of the patient's neck area. The glands and lymph nodes are checked for possible signs of inflammation as this could be a sign of general health problems. Dental X- may also be necessary. A risk assessment should be performed that involves evaluation of the patient in light of the patient's physical status and medical health, as well as the type and extent of the planned dental procedures. In general, nonsurgical dental procedures carry less risk compared with invasive, surgical, and traumatic procedures.

Some items included in the assessment of the patient may include, but are not limited to:

  • Medical history
  • Surgical history
  • Anesthesia history –adverse reactions to anesthesia
  • Allergies
  • List of medications that the patient is taking and when they were last taken

Discharge Instructions

Discharge instructions will vary depending on the dental procedure the patient undergoes. Fillings, gum treatments, implants, etc. should have individualized discharge instructions for the patient to follow.  It is important that these discharge instructions are reviewed with the patient and that the patient verbalizes understanding of these instructions. A copy of the instructions should be given to the patient on discharge from the office/clinic.  It is important to include in these instructions what to do if there is excessive pain, bleeding, swelling, etc.  Included in the instructions should be a contact number for the dentist as well as what to do if the dentist cannot be contacted.

In summary, the safety of the patient is the top priority when dealing with dental patients.  Ensuring that water quality is monitored and maintained, amalgam is disposed of correctly, and imaging is performed with proper protection is of the utmost importance.  Along with these, assessment, consent for the procedure, and discharge instructions rate high on the list for safe patient care and patient satisfaction.


  • Guidelines for Infection Control in Dental Health-care Settings – 2003. MMWR2003; 52(No. RR-17):1–66.
  • Management of Medical Emergencies in the Dental Office: Conditions in Each Country, the Extent of Treatment by the Dentist, Daniel A Haas, The Journal of Sedation and Anesthesiolgy in Dentistry: Anesthesia Progress,
  • American Dental Association website.
  • Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings:  Basic Expectations for Safe Care. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; October 2016.

To learn more about Dental Service Regulatory Compliance contact the Courtemanche and Associates Team at 704-573-4535 or email us at


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