Dentists need to stay on top of the ever-changing landscape for sterilization, PPE, and more.
A physician showing some of today's individual protection elements. Davizro Photography/ADOBE.STOCK.COM
Standard infection control practices are bedrock, bread-and-butter staples. That is, not much has changed in the world of hand hygiene and the importance of hand washing. But, over time, some products, processes, and procedures have changed. If practices haven’t kept up with the changing face of infection control, they may be erroneously (while still with the best intentions) performing something an outdated way.
Delivering properly processed instruments to patients is conventionally achieved through steam sterilization. However, some practices may still be reprocessing instruments using outdated methods.
“A lot of what’s changed has to do with what we used to call chemical sterilization, or cold sterilizing, items,” infection prevention speaker, author, and consultant Mary Govoni says. “Most everything we use now in dentistry is either heat sterilizable, including plastics, or it’s disposable. So there’s really not much, if any, need at all for chemical sterilants—and they’re actually not even referred to it that anymore. They’re simply called ‘high-level disinfectants’. There are two concerns: One is you can’t validate a chemical. So, you don’t know if an item is truly sterile when it comes out. And then, when it comes out, it has to be rinsed. So if you rinse it with tap water, then it’s not sterile anymore.”
High-level disinfection is necessary in some cases, but the concern is what happens with those chemicals once they have been used. These solutions, such as glutaraldehydes and OPA, can and should be neutralized, before pouring the solution down the sink. In some states the solutions must be disposed of through a waste disposal company.
There are different arenas in which dental professionals have to practice infection control. In the past, bloodborne pathogens seemed to get the most attention. But, in a post-COVID-19 world, airborne threats are center stage.
“We have to give everything the same precautions, because, obviously, it’s an airborne illness,” says Dr. Lisa Kane, DMD, Dental Consultant at Dental Office Compliance of New England. “Before, we were more worried about bloodborne pathogens. We were always taught to take off PPE before you leave the room, never come in the room all donned with PPE. Now, you’re supposed to always have respiratory and eye protection before you see the patient and then have it on afterwards. The only thing that you’re putting on when you’re getting in the room are gloves, and then you need to take them off before you leave the room.”
It shouldn’t be a hard adjustment to make, because mitigating the effects of aerosols was always something that should’ve been heeded.
“I would hope that people were doing that before,” Kane says. “A lot of people were not doing that before they were leaving the operatory with PPE, anyway, which was wrong. People are overwhelmed with this whole situation and they’re really scared.”
Some confusion may exist because of conflicting messages from regulatory agencies.
“What’s unfortunate is that the CDC and OSHA say different things, as of this interview,” Kane says. “The CDC is telling you that if you’re doing an aerosol-producing procedure, yes, you should wear an N95 respirator or higher, but if you don’t have that, then you can use a surgical mask and face shield. But OSHA is definitely saying that, on a well patient, if you’re doing an aerosol-generating procedure, they want you to have an N95 or higher.”
Another variable to consider is that guidance differs state-by-state, depending on OSHA rules.
“In Massachusetts, for example, whatever OSHA and CDC say, you have to follow–they’re not guidelines, they are rules,” Kane says. “That creates confusion, because there’s a handful of states that say that whatever the CDC and OSHA says are the rules, and I think that people are having a really hard time trying to figure out, ‘Who do I listen to?’”
PPE and its usage have also been thrown into a state of flux, thanks to the times.
“PPE has just been totally set on its ear, mostly because of respiratory protection,” Govoni observes. “Prior to COVID-19, many practices did not know, or didn’t pay attention to, the ASTM level of their face masks, so they weren’t, necessarily, wearing the appropriate face mask for what the task was that they were doing. We’re looking at wearing a level three, which is the highest level of protection for a face mask on the ASTM system, for pretty much all procedures at this point. Face masks are disposable, meaning one face mask per patient, and the emergency use authorization from the Food and Drug Administration is a little murky about the reuse of face masks in short supply. In some emergency situations, if you don’t have enough and you’re wearing a full face shield, depending on your situation, you might be able to reuse them.”
A unique PPE challenge, thanks to COVID, has been the scarcity of equipment, especially masks and respirators.
“I think practices are using short supply as an excuse not to change that face mask,” Govoni says. “Even if they do have access to them, respirators, of course, have not been regularly used, and now OSHA is recommending N95 respirators or higher protection. And CDC’s interim guidance also says the same thing. But, then again, folks are challenged with getting supplies.”
Another component to PPE, especially as N95 masks are concerned, is proper use.
“The biggest change with using respirators is that they need to be fit-tested,” Govoni says. “And although OSHA has relaxed or suspended its rule for annual fit-testing of employees that wear respirators, they haven’t relaxed the requirement for initial fit-testing of respirators. So, in other words, if you’ve never worn a respirator before, you have to be fit-tested with the brand of respirator that you’re going to wear, and if you change brands, then you have to do a fit-test procedure again to make sure that it’s doing its job.”
Especially for practices that don’t have a lot of experience using N95 masks, they can’t just be used on the spur the moment.
“A lot of people are doing that,” Govoni observes. “I think for those practices that are actually wearing their respirators, they’re wearing them while they’re treating patients. Some of them are having issues with feeling lightheaded or anxious—actual physical symptoms from decreased oxygen from wearing the respirators. And so they certainly need to have them checked with fit-testing and make sure it’s the right respirator for them. But they also can take them off when they’re not treating a patient or not in an area where there’s an aerosol-producing procedure being done, where they can have a break. CDC requires that you have a mask on at all times, so when you come in to the facility in the morning and you’re maybe in the break room, or you’re getting things ready, you need to have a face mask on. It does not have to be a respirator. And the CDC says it can even be a cloth mask. Then, when you go in to do a procedure on a patient, is when you would put your N95 respirator on and all your other PPE. In the past, face masks were only worn when we were treating patients and then we would take the face mask off and not wear a mask around the office all the time.”
Check your products
The products used by the practice should be checked to ensure that they are being used for the right applications and in the right way.
“It’s really important to do things correctly,” Kane observes. “It’s really important to make sure that your disinfecting is appropriate for all viruses and emerging pathogens. And it’s really important that you make sure that you’re actually using your disinfectant properly. Some of them had certain contact times before this, and now they’ve upped them. So, it’s important to know that and not just assume that it is exactly how it was.”
Finding the right information on which disinfectant to use to combat the SARS-CoV-2 virus is available under List N on the EPA’s website.
Another way in which COVID-19 has affected the equipment used in dental practices is how air circulation is managed.
“One of the major changes would be with air circulation in treatment rooms,” Govoni observes. “The CDC’s interim guidance suggests that practices have a consultation with an HVAC professional so that they know the number of air exchanges that are taking place in a room to clear some of the aerosols that remain in the air. And, do they have appropriate filtration in their HVAC system? The CDC is also recommending that individual air purifiers, like HEPA filtering units, be placed in treatment rooms to clear those aerosols and refresh the room air. So that’s a big change. There’s some controversy about whether we should wait for a certain amount of time after we finish treating a patient before we start cleaning up for the particles that may be suspended in the air to settle out.”
But it isn’t just equipment that can help mitigate airborne threats—proper technique matters.
“The CDC originally said wait 15 minutes,” Govoni says. “Then they took the 15 minutes away and said, ‘Well, you really should go by what the number of air exchanges and what your air filtration systems are doing in your practice, which may mean that it’s either a shorter time or a longer time.’ But the ADA has taken a stance, which I agree with, that 15 minutes is probably a realistic time in most treatment rooms. Those are some changes that we didn’t think about before, because in the past, what we did was dismiss the patient and immediately start cleaning up and disinfecting the room. We didn’t wait for any aerosols to settle. We didn’t really pay much attention to the aerosols before, which we should have.”
While some aspects of infection control are standard, boilerplate matters, others continue to evolve. Keeping up on current rules, regulations, and recommendations ensures that you are still doing things the proper way.