I am writing in support of the rulemaking petition proposing to require dental assistants in Virginia to pass the Infection Control (ICE) and Radiation Health and Safety (RHS) exams administered by the Dental Assisting National Board, Inc. (DANB) or to earn DANB’s NELDA certification.

The risk of transmission of infection in a dental office is a serious concern, and these concerns have been heightened by a series of high-profile breaches of infection control protocols reported in the media, including the following:

• In 2014, New Jersey public health officials discovered 15 cases of endocarditis linked to improper infection prevention procedures at one oral surgery office; of the 15 confirmed endocarditis patients, 12 underwent cardiac surgery and one died from complications of endocarditis and subsequent cardiac surgery.[i]

• In a highly publicized incident in Oklahoma in 2013, more than 4,200 dental patients required testing for infectious diseases after receiving treatment in the office of an oral surgeon whose staff was found to be using improper sterilization practices. Of those tested, 89 were positive for hepatitis C, with at least one of these cases confirmed through genetic testing as a patient-to-patient transmission of the disease.^[ii] Though it is unclear whether this oral surgeon’s assistants had any formal training or education, it is known that they did not hold DANB’s Certified Dental Assistant certification and had not taken DANB’s Infection Control exam, which is a component of the CDA certification.

At the time of the incident, Oklahoma did not have any laws or regulations requiring dental assistants to receive any specific education or training in infection control or to hold independent professional certification in dental assisting from DANB or any other entity. The supervising dentist, in a statement to investigators, indicated that he delegated all sterilization responsibilities to his dental assisting staff, yet the errors made by these assistants demonstrated that they lacked even a basic knowledge of infection control principles, including those on which they would have been comprehensively tested had they taken DANB’s Infection Control exam and/or been holders of DANB’s CDA certification.

• The Oklahoma incident described above followed a series of significant but less well publicized infection control breaches, including one in which more than 500 veterans were notified that they might have been exposed to hepatitis B, hepatitis C, and HIV after having procedures performed in a VA dental clinic where proper infection control protocols were not followed.^[iii]

In Virginia, there have been at least two allegations of breaches in the past two years, including one incident in which a dentist in a Richmond pediatric dental office informed patients that the practice’s one high-speed handpiece was not being heat sterilized between patients, but only wiped with an intermediate disinfectant. The practice is also accused of improperly maintaining water lines.[iv] In another case, a lawsuit filed in May 2019 alleges that employees/agents of a dental clinic owned by a company based in Roanoke used improperly sterilized instruments on at least 50 patients.[v]

The DALE Foundation, the official affiliate of the Dental Assisting National Board, Inc. (DANB), conducted a research study in 2016 focused on the value of dental assistants to dental practices. The cornerstone of the study was a survey that researchers circulated to dentists, dental assistants and dental hygienists in general dental practices; the survey included questions about delegation of duties to dental assistants.

The survey responses revealed the following related to delegation of infection control-related tasks to dental assistants:

• 69% of responding dentist and dental assistants indicated that “perform sterilization and infection control procedures” is one of the top five functions most frequently delegated to dental assistants
• 99% of responding dentists and dental assistants indicated that “perform sterilization and infection control procedures” is a function delegated to dental assistants; 28% indicated that this function was performed by qualified dental assistants, and 71% indicated that this function is performed by all dental assistants, including those who have not met any specific requirements[vi]

The consequences to the public of improper performance of infection prevention and control procedures can be very serious. Survey data indicate that dental assistants are performing sterilization and infection control procedures in 99% of general dental practices.  However, because Virginia does not regulate first-level dental assistants (Dental Assistants I), we don’t know how many dental assistants in Virginia do not have adequate training in infection control.

According to occupational employment statistics available from the U.S. Bureau of Labor Statistics, there were approximately 8,520 dental assistants employed in Virginia in May 2018. In January of that year, there were 2,400 dental assistants with Virginia addresses who had passed DANB’s Infection Control (ICE) exam since 1997, which is less than one third of all employed dental assistants. While it is possible that the approximately two thirds of dental assistants in Virginia who have not passed DANB’s ICE exam have received some type of formal education or training in infection prevention and control, there is simply no way to know. The good news is that, if Virginia adopts a requirement that all dental assistants must pass the ICE exam, approximately one third of assistants will have already met this requirement.

I am in full agreement with dental assistants being required to take DANB’s Infection Control Exam.  I have worked in dentistry in Virginia for 37 years as a clinician, a dental sales consultant, and an educator and administrator.  From my own experiences, I can say that the need for all dental assistants to be educated in infection control is crucial for the safety of dental professionals and our patients. 

I worked for 27 years in the same dental office. In my first few years as a dental assistant, I also thought infection control was not an issue, because the dental office where I worked employed highly educated dental assistants (including me) that believed in continuing education and maintaining current knowledge of the latest technology.  When I started temping as a dental hygienist on my days off, I realized that not every office maintained the same standards.  On several occasions, a dental assistant in the office where I was temping would give me an orientation to the office’s sterilization process and procedures, and I was frequently shocked at the deviations in best practices that I saw.

As a dental sales representative, I visited hundreds of dental offices in Virginia and had the opportunity to learn quite a bit about the way different offices operate. I wish I had kept a record of how many offices didn’t know the OSHA guidelines and the mandated rule to have office training in the bloodborne pathogens standard each year.  I am not aware of anyone checking to see if dental offices comply with this mandate.

Ten years ago, I became an educator and director of a dental assisting program that has four campuses located throughout Virginia.  This role has ignited a passion in me for the profession of dental assisting and reinforced my belief that there is a critical need for dental assistants who are properly trained and educated and who are certified.

My students all take and pass DANB’s Infection Control Exam before going on externship/internship and have demonstrated mastery of proper infection control concepts and procedures. They regularly bring stories back to class of appalling deviations from the best practices they have learned.  While I recognize these are second-hand anecdotal accounts, they cause me to be deeply concerned about the health and safety of dental patients in Virginia.  

In 2015, I served on the Regulatory Advisory Committee on the Education and Practice of Dental Assistants I and II.  The committee recommended that the Virginia Board of Dentistry adopt infection control requirements for dental assistants.  In the Board’s discussion, it was stated that there are no issues with infection control in Virginia.  I am certain that the Board members expressing this view were indeed following best practices in their own offices. But I am not aware of anyone checking or inspecting offices for proper infection control, and so I am not sure where the belief that there is “no issue” comes from.

To fully protect the public, I ask the Board to address the incorrect infection control protocols or disinfecting and sterilization issues that are happening all over Virginia by adopting a requirement that all dental assistants be required to pass DANB’s Infection Control exam. 

Regarding radiography requirements:

As of March 2019, 3,698 individuals had passed DANB’s Radiation Health and Safety (RHS) exam since 1997, representing less than half of all dental assistants in Virginia. This means that more than half of Virginia dental assistants have qualified to perform radiography procedures by passing the ARRT certification exam, which is not specific to dentistry and contains very little, if any, content on dental radiography, or by taking a course from a CODA-accredited program. Because many of the radiography courses offered in Virginia are themselves not accredited (though they may be offered by an accredited program), they do not follow a standard curriculum and there is significant variability in content, duration of hands-on instruction and assessment in these courses.

DANB’s RHS exam is a standardized exam, the content of which is based on a formal study to determine the tasks that are actually performed by dental assistants on the job and the knowledge that is needed to perform those tasks safely and competently. Dental assistants who pass DANB’s RHS exam demonstrate mastery of a standardized body of knowledge. Requiring DANB’s RHS exam for all dental assistants who perform radiography procedures will provide the Virginia Board of Dentistry with the means of verifying that dental assistants who perform radiography have the required knowledge to do their jobs safely.

I agree with the petition.