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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
While clinical equipment makes clinicians' lives easier, it can present its own set of challenges when it comes to disinfection.
High-tech clinical equipment, such as CAD/CAM, sensors, cameras, intraoral scanners, handpieces and so forth, makes clinicians’ lives (and patients’ outcomes) much better. However, it can pose its own unique sets of challenges, especially when cleaning and disinfection are involved.
“It seems to be a really challenging issue for dentistry, partly because dentistry has become more equipment-dependent,” says Peggy Spitzer, a dental hygienist and clinical education manager for Certol International. “There is more technology-it’s terrific technology-but it tends to get designed for the functionality with little or no thought about how to disinfect and how to make it safe for the next patient.”
There’s a difference between sterilization and disinfection. Disinfection inactivates some-but not all-microorganisms, while sterilization eliminates all microorganisms, usually through steam heat. That may not, obviously, be possible with a piece of sensitive electronic equipment.
“Any device that enters the patient’s mouth should be heat-sterilized if possible,” says Eve Cuny, assistant dean for global relations and director of environmental health and safety at the Pacific Dugoni School of Dentistry. “If heat sterilization is not feasible, then a high-level disinfectant is recommended for these semi-critical devices (devices that come into contact with oral tissues but are not surgical in nature). Clinicians do not have the ability to validate decontamination procedures, nor can they test the disinfectants, to determine if they can harm the materials in the device being disinfected. Therefore, the manufacturer should be consulted regarding how to safely and effectively decontaminate the equipment.”
Intraoral cameras and digital sensors do enter the patient’s mouth, but the manufacturer’s instructions usually don’t allow soaking in liquid chemical for high-level disinfection. A combination of mild cleaners, intermediate level disinfectants and intact barriers may be needed. Each piece of equipment will have its own type of exposure to biohazardous material, and each piece of equipment requires its own means of protection and cleaning.
Manufacturers of intraoral cameras and sensors may recommend a combination of intermediate level surface disinfectant and barriers.
“There are a variety of products out there now, including keyboards, that are resistant to water and chemicals,” Spitzer says. “Those items may be cleaned and disinfected quite freely. Clinicians have used plastic wrap and baggie-type barriers, but that type of product is not typically FDA-cleared. Companies do offer FDA 510(k)-cleared barriers with verified thickness that can be slid over a keyboard or device, then you take it off after the patient, like you do with all the other barriers.”
As equipment has gained traction in clinics, it has become more robust and durable, making it easier to clean.
“There’s been an evolution/revolution as these items become more commonly used, and I would say, particularly in the case of intraoral cameras, digital radiography, the little sensors and intraoral cameras, that’s technology that’s pretty mature now,” Spitzer observes. “The devices are more sturdy. They can withstand disinfection. Some of the early sensors were a little too fragile. Probably some of the early intraoral camera wands were a little too easy for fluids to invade.”
Barriers are great way to make sure that sensitive electronic equipment isn’t contaminated, but Spitzer advises making sure the barrier is intact with no holes or defects.
“They need to check and make sure that the barrier that they’re putting on there is intact,” Spitzer says. “There are manufacturing errors. It’s just little plastic bag. It zips through a machine, so just do a simple look at the bag and make sure it’s intact. It merits paying attention because the barrier for those devices in dentistry is important. It really helps manage the process taking it from patient to patient.”
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Believe it or not, the technology behind touchscreens can be traced back to the mid-1960s. And while they slowly and steadily gained a foothold in research and industrial fields, it wasn’t until 2007 that the technology became such an omnipresent part of life. Touchscreens are everywhere from smartphones to tablets to devices used in medical and dental settings. While those devices are easy enough to use, they pose problems in a healthcare setting.
“Touchscreens may come into contact with spray and spatter from the patient’s mouth generated during dental procedures,” Cuny says. “In addition, it may be necessary to touch the screen during patient care while the clinician is wearing gloves. This may be necessary to look at additional X-rays, review something in the medical or dental history, or refer to prior treatment in the treatment notes. These activities may result in contamination of the screen with patient body fluids.”
“My experience with touchscreens is that they are incredible, they are awesome and they cannot be disinfected,” Spitzer adds.
Ideally, the manufacturer will provide guidance for correct and proper cleaning and sanitization of touchscreen devices.
“For medical/dental devices, the manufacturer’s instructions should be followed, and if instructions are not provided, the manufacturer should be contacted and instructions requested,” Cuny says. “For nonmedical devices such as tablets or touchscreen computers, a clear plastic barrier may be used to prevent contamination. The barrier should be changed between patients. Unless the manufacturer of the touchscreen provides instructions for sanitizing, it is not advisable to use cleaning and antimicrobial products since they may damage the device. There are computer screens that are available in the medical market that may be cleaned and disinfected using disinfectant wipes. The specific type of disinfectant will be identified in the instructions for use.”
Because touchscreen equipment is so new, the industry faces growing pains, something that Spitzer sees when dental schools invest in new technology and reach out for help.
“They’ll call sometimes after they’ve invested in a whole clinic is full of touchscreens and they will say, ‘Do you have any idea what we can use? Do you have any kind of product that we can use?’” Spitzer says. “There’s just not much you can do about touchscreens. They should be touching them with a stylus or some sort of cover over their hand or finger that’s not going back in the patient’s mouth. I know for sure there are some CAD/CAM screens that are designed to be used with a stylus, but they don’t bother with that stylus. They just go out of the patient’s mouth and touch the screen.”
Manufacturer’s instructions for use
With any piece of equipment in the dental office, the best place to make sure it’s being used and maintained properly is by consulting the manufacturer’s instructions for use (IFU).
“It’s a good idea to maintain and review the manufacturer’s instructions for use for all equipment as a reference guide,” Cuny says. “Priority areas for reprocessing are parts of the device that contact oral tissues, followed by those that may be touched during patient uses with the clinician’s gloved hand, or between uses by the clinician’s bare hands. Touch surfaces should be barrier protected with barriers changed between each patient, or cleaned and disinfected using an appropriate level disinfectant (a minimum of low-level if no visible blood contamination, intermediate-level if blood is present).”
It may seem like reading the directions for proper maintenance is a given, but too often, once the device is up and running, the instructions get set aside.
“The clinician must have the instructions for use,” Spitzer says. “It’s very expensive equipment that they’ve doled out a lot of money for, and then the instructions kind of get shoved to one side. Beyond being able to turn it on and use it, they don’t always go back to it and find out if there’s anything in there about cleaning and disinfecting it.”
A great way to make sure met the equipment can be properly maintained is by including that consideration when shopping for new technology.
“It’s always advisable to look at reprocessing or decontamination instructions as part of the process of equipment selection to ensure adequate instructions are included,” Cuny says. “If they are not and the manufacturer cannot provide them, the clinician should consider a similar product that does have adequate instructions. If they find themselves in the situation where they do not have instructions, they should contact the manufacturer and ask for them.”
“You should think about it when you’re purchasing the product,” Spitzer adds. “They get so excited about the technology and understanding how it can be used and what it can do for their production that the very last thing most of them think is ‘How can I reprocess this? What do I have to do for maintenance? What do I have to do to keep it safe for the next patient?’ They never think about that until they’ve gotten in the office, they paid for it, and now they just have to deal with it. The question should come up before a check or anything else changes hands because then they have bargaining power. They can get the ear of the company because the company wants to actually make the sale. So, we’ll make sure that they get to the technical department and the technical department will be motivated to give them the proper answers because they’ve got a potential customer.”
High-tech clinical equipment certainly improves the quality of dentistry. But while they provide easy, effective treatment mechanisms, they require their own set of cleaning and maintenance measures.