BDJ in Practice spoke to the Patron of the Society of British Dental Nurses, Fiona Ellwood, about what the last eight years have meant for the dental team in regards to compliance and regulatory issues:
In your view why was HTM 01-05 so significant?
Decontamination and infection prevention and control were always part
of core training for dental professionals and particularly for the
dental nurse; prior to the introduction of HTM 01-05, but when we look
at significant developments and key changes, the publication of the
requirements and the document went a long way in basing what we did and
would do on better practice. It’s not too much of an exaggeration to
suggest things changed forever – and for the better – at that point.
Dentistry is a fast-moving profession, so how often does HTM 01-05 get looked at?
It has been reviewed and the second edition was issued in 2013, but
there were a number of amendments introduced before then. I’m led to
believe the latest review of the standards should have already been
I do think it is important documents like this are reviewed
frequently. We as dental professionals always look for what we do and
how we do it to be evidence-based. The problem many practitioners found
when it was first released was that some of the requirements were not
always evidence based. Some of the amendments introduced over time,
such as the storing and packaging of instruments, was done so on the
basis of new information being presented.
So what was the biggest change pre and post HTM 01-05?
For me the answer is twofold. Decontamination and infection
prevention and control standards in the community dental and hospital
services were already structured and streamlined. Those working in
general dental practice were operating their standards more by way of
unwritten rules and what they considered to be the right thing to do.
For those, the change was enormous.
Looking back those in hospitals and community dental services were
probably better equipped than general dental practitioners and one-man
practices who may have found it quite a challenging change. The workflow
had to change and it had the potential to be costly – practice owners
were expected to buy new equipment, for example. Timeframes had to
For example the dental nurse who was already undertaking a large
number of duties on top of caring for the patient had to add these extra
measures to the list as well. For those with the revenue, they employed
‘decontamination assistants’, but the principle remained the same – it
added time and cost, but with inferred better patient outcomes. It could
be recognised by some as further financial outgoings not long after the
economic crash in 2008. The structure, the flow, the consistency and
the way we approached packaging and the continual monitoring were the
Fast forward eight years. That document is embedded. It’s now
part of everyday life in practice, but what is the impact of those
changes and developments?
If you talk to dental nurses involved in the work stream, if it has
been part of their training and they were born into the profession
after 2009, they don’t know any different – it’s always been a part of
their job. Those who were part of the change have adapted – because they
had no choice – but they have adapted well. The challenge for many
dental teams is now keeping their knowledge up to date. That’s proving
to be more difficult than it sounds.
There are mixed messages on what you should/should not be using.
Unfortunately we are increasingly seeing individuals and companies
providing CPD from a sales perspective rather than theoretical and
learning perspective. Throw in antibiotic stewardship and the need for a
wider understanding of why those issues are important and there is a
huge expectation on dental nurses and the entire dental team to
understand the ‘why’ element.
What are some of these mixed messages?
Take the changing and use of gloves for example. There are different
types of gloves for different procedures, but the issue is more the use
of cleaning agents such as hand washes and hand rubs between changing
them. Some take the former as a replacement for the latter, and that is
absolutely not best practice.
Where do these mixed messages originate?
There are a variety of sources, and that in itself is a problem. We
have the guidance yet many professionals interpret what is said in a
number of ways. As a Society we take a great deal of guidance from one
of our Fellows who specialises in oral microbiology for dentistry. We
also have decontamination leads within the Society, and I am the
co-programme lead on the infection control lead module on the foundation
degree at the University of Chester.
Is that something you would recommend?
HTM 01-05 recommends you appoint a decontamination lead. Sadly we
still hear about practitioners taking on the responsibility and juggling
multiple expectations rather than delegating this to an identified
lead. There isn’t really a group to share best practice with, so it’s
done on an ad-hoc basis. Everyone draws from a different point
of knowledge. This is a vital component of the Society as it helps keeps
the membership informed and offers support.
Could HTM 01-05 go one step further than recommending one is appointed?
I believe that this role is essential if the dental team are to be
well informed and are to exercise best working practice. Yes there
would be challenges with not only implementing the directive, but who
would give it in the first place and who would monitor it in the long
term. I firmly believe decontamination and infection prevention and
control standards are so important for the dental team that this should
be considered. Perhaps it could become at the very least a ‘notable
practice’ consideration from the CQC.
So what should people looking for CPD in this area consider?
If I look at the courses out there, there is a criteria I would
encourage people to look at before attending. Does it meet GDC
standards? Does it meet CQC? Does it meet both? As with anything that is
potentially product-driven, there will be an agenda behind it. This is
such an important topic we have to look beyond that.
Find a competent and preferably qualified or trained lecturer/speaker
who you feel comfortable with and believe has the knowledge to deliver
the information and who can award CPD and undertakes quality assurance
practice along with an intention to assess learning. NSK have
developed some short courses which I have contributed towards and they
were deliberately assessed against the GDC requirements, what the CQC
says and what the current standards are and their quality assurance
The Society has also developed an accreditation approval scheme so
that dental nurses can easily see that CPD courses meet an expected and
required standard. That’s quite an important point for not only dental
nurses to consider, but for the principal dentist too. When registration
was introduced for dental care professionals, dental nurses then had
ownership of their professional position and an expectation of learning.
No longer were dental nurses expected to turn up, do their job and go
home; they were expected to become involved as wider members of the
dental team and of life-long learning.
You mentioned antimicrobial stewardship earlier. How does that play a role?
We are trying to keep dental nurses informed about effective
infection prevention and control. We can reduce the risk of infections
developing and spreading by educating those within the team responsible
for decontamination and infection prevention and control, highlighting
how these things start and identifying how we can break that chain. If
they don’t understand what they’re doing, they won’t be in a position to
participate in effective infection prevention and control.
Do you think extended roles within the dental team is a benefit?
Absolutely. Extended roles are a huge benefit. If you take
the community dental services as an example, who have a decontamination
lead, the person responsible undertakes the monitoring, auditing and
competence checks as well as delivering training and updates to the
teams. I go back to responsibility and accountability too. It can keep
dental nurses motivated and help with staff retention.
I was chatting to a dental nurse not long ago who said she could earn
more stacking shelves, this cannot be right – it is far from a
well-paid career and many are in the job because they care for people,
but we should consider the true role of the dental nurse. Developing a
dental nurse who is passionate about decontamination and infection
prevention and control standards can be an asset to any dental setting.
Is there one point you want to emphasise when it comes to standards?
That’s simple! Not to assume everyone knows what they’re doing. It’s a
funny thing to say given the level of qualifications and training
needed to enter the profession, but it’s a dangerous, but often a
natural assumption to make. Sometimes we find the induction process is
quite often poor, so the key thing is continual training to ensure you
and the team are up to date. If registered dental nurses join the team
or act as locus nurses, we should never assume they are trained to the
same level or way of the practice. After all there are three different
routes to the point of sterilisation outlined in HTM 01-05.
What do you consider to be good practice for an induction?
Whoever is named as the decontamination and infection prevention lead
should spend time getting those new to the practice up to speed with a
standardised training procedure long before they start working. A model
of not being thrown in at the deep end and escalating into poor working
practice is a good way to approach it.
You always have to consider the implications of your working
practice, the CQC and the standards set by the GDC – ‘patients have a
right to be treated in a clean and safe environment’. Ask yourself; what
would your team say about your procedures? What would your patients
want to know? It may be useful to promote your decontamination lead in
your practice reception or newsletter.
It was interesting to note the CQC report into dentistry was positive
for infection control, but well-led was one area for improvement. For
me, well-led crosses over into infection control. A well-led practice in
the first instance puts in place a framework that has been developed
with the team, it pre-empts potential happenings rather than fire fights
and has the ability to deal with situations that arise when you don’t
expect them. It also means they have processes and fail safes in place
to ensure they don’t happen again. I’d consider this in the induction
Note: An updated version of this article was published in
the August 2017 edition of BDJ in Practice, clarifying some points from
the previously published July 2017 article.
Achieving high standards in infection control: training course
Our training course, Achieving high standards in infection control
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Essential decontamination certification
Our certification course
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