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Kara Vavrosky, RDH is an Editorial Director at Modern Hygienist, a part of the Modern Dental Network. She is best known for running the popular Facebook page, Dental Hygiene with Kara RDH, and is the founder of DentalHygieneAnswers.com, a Q&A site for dental hygienists. Kara also serves on multiple advisory boards for dental-related companies and is a 2015-2016 ADHA Governance of Tomorrow Steering Committee member. You can learn more about Kara at KaraRDH.com.
As hygienists, infection control and the safety of our patients is a top priority. But are you and your office up to date on infection control protocols and required infection control training? Here are five infection control mistakes you might be making and not even realize.
As dental professionals, infection control and the safety of our patients is a top priority. But are you and your office up to date on infection control protocols and required infection control training?
Just because you or your office has always done something a certain way, doesn’t necessarily make it correct. Protocols and best practices are constantly changing. For the safety of our patients, and even ourselves as clinicians, reviewing infection control protocols needs to be at the forefront of our priorities. Here are five infection control mistakes you might be making and not even realize.
Slow-speed handpieces do not need to be sterilized between each patient. Barriers and surface disinfection is fine.
Slow-speed handpieces are considered semi-critical devices, so you may think disinfecting with a surface disinfectant and using a plastic barrier is proper infection control. Not the case! According to the Centers for Disease Control and Prevention (CDC), handpieces are an exception to this rule because “studies have shown that handpieces can become contaminated internally with patient materials and the next patient may be exposed to potentially infectious materials.”2,3,5 The CDC states that handpieces “should always be heat sterilized after each patient.” But what if the handpiece motor isn’t removable from the dental unit air or waterlines? The CDC’s response to that is, “handpieces that cannot be heat sterilized should not be used.”7
To be compliant with CDC recommendations you need more than one handpiece so they have time to be heat sterilized in between each patient. Saying they are “too expensive” to buy more than one handpiece is not an excuse the CDC is likely to entertain. A dental office is a business, and to run a business there are costs. Your office wouldn’t choose not to buy a sterilizer because it’s too expensive; it’s a cost of doing business. Equipment such as handpieces should be looked at just the same-a cost of doing business.
All disinfectant wipes are equally effective at cleaning blood.
In order to disinfect a clinical contact surface, it must first be cleaned of debris such as saliva, blood, exudate, bioburden, and then disinfected. The wipe-discard-wipe method is used to first wipe for cleaning debris because these debris can interfere with the effectiveness of the disinfectant. In a second pass, a new wipe is used to disinfect.2,7
For cleaning, the CDC requires at least a low-level EPA-registered hospital disinfectant (HIV and HBV claim) to be used. If the surface is visibly contaminated with blood (like in many dental situations), the CDC requires an intermediate-level product (with a tuberculocidal claim) to be used for cleaning.2,7 However the CDC states, “Not all disinfectant products should be used as cleaners unless the label indicates the product is suitable for such use.”2 So the question becomes, are you cleaning (first wipe) with an effective cleaning product? Again, this is important because if the surface isn’t properly cleaned, proper disinfection cannot occur.
An important factor to consider when choosing a cleaning product and its ability to clean, is alcohol content. Alcohols are poor cleaning agents in the presence of organic materials (blood, saliva, bioburden) because they cannot easily penetrate protein-rich materials including bacterial spores.1 Further, “following exposure to alcohol, denatured bioburden becomes more insoluble and tenaciously adherent onto most surfaces.”9 This is why water-based disinfectants are reportedly better cleaners than alcohol-based cleaners.1,9
So the next question becomes, do you know the alcohol content in your cleaning product? Is your cleaner water-based as recommended with low alcohol content (i.e. Caviwipes 17.2% isopropyl alcohol)? Or does it have a high alcohol content (i.e. Super Sani-cloth 55% isopropyl alcohol, Lysol III 58% ethyl alcohol, or Discide 63.25% isopropyl alcohol)? And further, does alcohol content really matter when it comes to cleaning blood? Studies show it does. A recent study compared these aforementioned products to test what role alcohol composition plays in accomplishing environmental asepsis.9 The focus was on the disinfectants’ ability to clean blood and bacteria (MRSA) from visibly soiled, hard surfaces. The low alcohol content disinfectant was able to consistently remove blood and bacteria (MRSA) as compared to high alcohol disinfectants. Most debris actually remained after cleaning with the high alcohol disinfectants.9
Read the labels on the disinfectant products you are using. Just because a product can disinfect, doesn’t necessarily mean it can clean. Proper cleaning must happen first in order to disinfect to keep patients safe!
When it comes to placing instrument pouches paper up or down in a sterilizer, what you learned in hygiene school is correct for all sterilizers.
What you learned in hygiene school was the manufacturer recommendations for the particular sterilizer your school had. Unless you are absolutely sure you are using the exact same model in your office that you used in hygiene school, what you did in hygiene school may not necessarily be correct for the sterilizer in your office now. Even if you think it’s the same sterilizer, it’s recommended to pull out the user guide and double check.
If you don’t have or can’t find the user guide for your office’s sterilizer, many manufacturer’s guides can be found online with a Google search or by going directly to the manufacturer’s website. If the user guide doesn’t state if sterilization pouches should be placed paper up or paper down, call or email the manufacturer directly. You can find contact information on the manufacturer’s website.
Many user guides state that the preferred orientation of pouches is actually resting on their edge, using a rack accessory to permit proper steam flow. However, if you must place directly on the rack, here’s what a few sterilizer manufacturers suggest:
Again, this does not mean all manufacturers recommend paper down, these are just a few examples.
A few more reminders: Pouches should be loosely packed and not piled or stacked on top of each other as again, proper steam flow must occur. Many user guides even include maximum capacities for instruments, handpieces, weight and thickness that can go on a single rack in the sterilizer. Be sure to let instrument pouches dry completely before touching them. If the pouches are touched, moisture acts like a wick and can draw bacteria from your hands, the environment or the surface they are placed on, pass through the packaging and contaminate the instruments.7 Lastly, the CDC states, “Packages should be labeled to show the sterilizer used, the cycle or load number, the date of sterilization, and, if applicable, the expiration date. This information can help in retrieving processed items in the event of an instrument processing/sterilization failure.”2
Using a cassette to transport contaminated instruments from the operatory to the sterilization area is up to OSHA standards.
Cassettes are a great way to keep instruments organized, reduce instrument breakage and keep handling of instruments during sterilization to a minimum, which helps protect against sharps injuries. However, for transporting contaminated instruments from the operatory to the sterilization area, they are not enough according to both the Organization for Asepsis and Prevention (OSAP) and the Occupational Safety & Health Administration (OSHA).10, 12 According to OSHA’s Bloodborne Pathogens Standard, “Contaminated materials that are to be decontaminated at a site away from the work area shall be placed in a durable (puncture-resistant), leak-proof, labeled or color-coded container that is closed before being removed from the work area.”12 The CDC states, “Minimize handling of loose contaminated instruments during transport to the instrument processing area. Use work-practice controls (e.g., carry instruments in a covered container) to minimize exposure potential.”7
Trays with locking covers are a great option for not only transporting contaminated instruments, but to keep instruments and patient care items safe from cross-contamination during storage, before patient treatment. Dental professional have enough risk of exposure to bloodborne pathogens, so using proper work-place controls to minimize risks is not only a need, it’s a requirement.
I’ve read this article, I’m now up-to-date on infection control protocols.
Alright, you’re probably not really thinking this, however it brings me to my last point of CDC requirements regarding an infection control training program for every dental office. Every office should conduct infection control training for employees that have an occupational risk of exposure, “at a minimum, annually” per CDC guidelines.7 Yes, your office must have infection control training at the very least once per year. The CDC also requires that when new employees are hired they should receive infection control training. Training should also be done if “new tasks or procedures are assigned to an employee that affect their occupational exposure.”7
A dental office also needs to have an “infection control coordinator who should be responsible for developing written infection prevention policies and procedures based on evidence-based guidelines, regulations, or standards. The infection prevention coordinator should ensure that equipment and supplies (e.g., hand hygiene products, safer devices to reduce percutaneous injuries, and personal protective equipment) are available and should maintain communication with all staff members to address specific issues or concerns related to infection prevention. In addition, all dental settings should have policies and protocols for early detection and management of potentially infectious persons at initial points of patient encounter.”2 Again, records must be kept on infection control policies, procedures, immunizations, and training. The requirement for infection control training and having an infection control coordinator is by no means new information and can be found readily in the 2003 CDC recommendations.7 So if your office is not abiding by these requirements, the time is NOW!
1) Blue, C.M. (2017). Darby’s Comprehensive Review of Dental Hygiene (8th ed.). St Louis, MO: Elsevier.
2) Centers for Disease Control and Prevention. (2016, March). Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.
3) Chin J.R., Miller C.H., Palenik, C.J. (2006). Internal contamination of air-driven low-speed handpieces and attached prophy angles. J Am Dent Assoc. 137(9):1275-80. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16946433
4) Dierschke, H., Tuttnauer Service Manager. (2016, April 22). Personal communication: email.
5) Herd S., Chin J., Palenik C.J., Ofner S. (2007) The in vivo contamination of air-driven low-speed handpieces with prophylaxis angles. J Am Dent Assoc. 138(10):1360-5. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17908851
6) Hopkins, S., SciCan Technician. (2016, April 22). Personal communication: phone interview.
7) Kohn, W.G., Collins, A.S., Cleveland, J.L., Harte, J.A., Eklunt, K.J., Malvitz, D.M. Center for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings – 2003. MMWR 2003; 52 (Report No. 17). Retrieved from http://www.cdc.gov/mmwr/PDF/rr/rr5217.pdf
8) M9/M11 UltraClave Sterilizer User Guide: Models M9 (-020/-021 -022), M9D (-022), M11 (-020 / -021 / -022). (02-11-2016). Midmark, Versailles, Ohio. Retrieved from http://www.midmark.com/docs/librariesprovider6/pdfs/003-2707-99.pdf?sfvrsn=8
9) Molinari, J.A., Nelson, P. (2016). Environmental Surface Cleaning and Disinfection: Effects of Alcohol Concentration. (Report No. 27). Ann Arbor, Michigan: The Dental Advisor.
10) Organization for Asepsis and Prevention (OSAP). CDC Guidelines: From Policy to Practice. Retrieved from http://laneykay.com/wp-content/uploads/2015/06/instrumentProcessingOSAP.pdf
11) Rutala, W.A., Weber, D.J., the Healthcare Infection Control Practices Advisory Committee. Center for Disease Control and Prevention. (2008) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.
12) United States Department of Labor, Occupational Safety & Health Administration. (2012, April). Bloodborne Pathogens. Retrieved from https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051