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The challenges of balancing infection control and environmental responsibility.
As Kermit the Frog famously opined, it’s not easy, “Bein’ Green”. The beloved song from 1970 was about race and identity, but the tune has been adopted to address ecological concerns as well. Dental practices have an especially fine line to walk when it comes to environmental responsibility and infection control.
Finding the fulcrum
Nobody wants to cause unnecessary harm to the environment, but by the same token, killing off the bad things necessitates potent chemicals. The key is finding the right product for the job; one that is effective, but not hazardous.
“I would hate to see someone using a product that they thought was healthier or safer and having it actually not be effective, from an infection control standpoint,” says Dr. Lisa Kane, DMD, Dental Consultant at Dental Office Compliance of New England. “I think you have to weigh the idea of adequate infection control with being environmentally friendly. As long as you can find something that is not going to compromise that high standard of disinfection and cleanliness, then I think it's great to think of something that is safer for you and the environment.”
“It's a balancing act,” says Mary Govoni, infection prevention speaker, author, and consultant. “I've struggled with this for a long time, because I am a big believer in being green and using less toxic chemicals, but we still haven't evolved yet. I don’t think that we are to the point where we can say that we've got a really good green solution, although I think it's coming.”
The answer, she considers, may not even be in a chemical.
“I think that, at some point, we will be able to utilize UV light for surface disinfection in our treatment rooms, but it's got to be safe for the user,” Govoni says. “In other words, eye protection from the light spectrum, and not just protecting the users, but other people who may be in the office as well, especially since we don't have enclosed operatories in many cases. But I don't know that we're quite there yet. I would love to see that happen.”
Strong, but not too strong
Disinfectant options exist, but those necessitate finding the right product for your needs.
“My favorite disinfectant is SciCan’s Optim,” Dr. Kane says. “It's accelerated hydrogen peroxide. If you look at the safety data sheet, it has no harmful ingredients. If you look at other products, they have many hazardous ingredients.You have to review what PPE you should be wearing [and] other safety concerns that will be on the SDS (Safety Data Sheet). Optim, and other similar products, are much safer for you and the environment. It’s not all about thinking just about the environment. You are in there every day using these products, and you're exposed to them constantly. If you can find something that's safer for you to be exposed to, I think that's great.”
In addition to all the other problems the pandemic created, there was a mad dash for disinfectant, which sometimes caused less than desirable results.
“At the beginning of the pandemic, there was so much emphasis on using disinfectants that are on the EPA list, and that had a claim against emerging pathogens human coronavirus and so forth.” Govoni says. “And some of the product manufacturers for disinfectants that we used a lot in the past didn't immediately have that label claim their products. So, many folks switched their disinfectant, and they may have not done as good of a job of controlling pathogens. It is important to note that the CDC Guidelines for Infection Control in Dental Healthcare Settings states that when there is blood present a disinfectant that is tuberculocidal must be used. Some products on the EPA List N do not have that label claim.In addition, the EPA clarified that if a product has a label claim for microorganisms that are more resistant or harder to kill than SARS-CoV-2, it is acceptable even if it isn’t on List N.”
Other options (other problems)
Other tools used for infection control pose their own problems. For instance, consider barriers. Barriers appear to eliminate the need for chemical use, but disinfectants are still necessary, and those barriers wind up going right into a landfill.
“The way that it's written in the CDC guidelines, it says that you can put barriers on, Or not, but have you to disinfect all surfaces,” Dr. Kane observes. “If you put a plastic barrier on surfaces, you still have to disinfect around the barriers. Regardless, even if you're putting barriers on, I think that you're still disinfecting everything. But there's so many things you're touching that you're not aware of, a lot of drawers and counters.”
That’s not to say that barriers aren’t effective. They also provide patient reassurance.
“The barriers provide a visual for the patient saying, ‘This is clean’,” Dr. Kane says. “And then it also is a convenience, because then you're not touching things that are hard to clean and hard to disinfect — grooves and things are protected.”
Ultimately, those barriers have to go somewhere and they are not recyclable.
“There's going to be consumables with those products,” Govoni says. “And if you don't want to use the chemicals, then you can use barriers, but barriers are certainly not green. Most of them are plastic and they don't break down in the landfill in any of our lifetimes. For a lot of practices, it's really a balance between what types of equipment or surfaces could easily be cleaned and disinfected with a product that isn't highly toxic, and maybe need some extra protection, then those things should have barriers.”
Other options that seem to have gained traction thanks to the pandemic, present their own downsides.
“Foggers that use hypochlorous acid and hydrogen peroxide are not so toxic,” Govoni says. “But it's the fact that if you're going to fog, and the idea was to kill the aerosols in the air. If you're going to fog a treatment room after every single patient, that's dispersing a lot of any kind of chemical into the air. And we don't have validated studies yet that show that that's effective in mitigating or taking care of any aerosol that might stay airborne after treatment was completed. We know that the hydrogen peroxide solution and the hypochlorous acid solution can kill the virus, but it hasn't been validated in studies of showing that it works through fogging. And we also don't know what the precipitates from the hypochlorous acid, for example, might do to equipment in the treatment room.”
Personal protective equipment (PPE) poses its own set of challenges. It has to be worn, but can’t be recycled or cleaned – with a few exceptions.
“The one thing that can be reused are the gowns that have to be worn when there's aerosol being generated,” Govoni says. “So they can either be laundered on site or they can be sent to a laundry service, as opposed to using disposables that you throw away after every patient that you did an aerosol-generating procedure on. But, in terms of the other types of PPE, face shields, of course, can be reused. They are cleaned and disinfected. For now, under the emergency use authorization from the FDA, N95 respirators that are supposed to be worn during aerosol-generating procedures can be reused, temporarily. We don't really know how long of a time, it just depends on whether the integrity of that respirator gets compromised at some point.”
“There are some respirators that are reusable with only filters that you change,” Dr. Kane adds. “You're still throwing stuff out, but you're not throwing out the respirator, the trash is probably less. As far as gowns, if you can find a nice washable gown that's water resistant, great. But then you're washing it at your office or you're sending it to a cleaning company, so I guess you have to weigh, ‘Is it landfill or is it water?’ What's your poison?”
The rest of the world and its infection control demands are impacting dental PPE supply needs.
“People outside of healthcare are wearing gloves, so they're in short supply, and there are people scrambling to make sure that they have enough to get through the next week or two of patients,” Govoni says. “And they're getting smaller orders than they're used to at one time. So, there are challenges. The N95 respirators are more available now because the manufacturers have done a good job of trying to allocate more of those resources into dentistry. Face masks are in better supply. We're getting some of that manufacturing moved back into the US, as opposed to in Asia, where many of them have been manufactured. So that's getting better. I don't know how long it's going to take to get caught up on the glove manufacturing. I'm hearing that many of the glove manufacturers are trying to move their manufacturing back into the US, but it's typically done again in Asia, because that's where they get the chemicals and it's where they got most of the natural rubber latex from. So, we are just between a rock and a hard place.”
Being ecologically responsible is certainly noble, and individual practices are on their own journey in that regard. However, COVID threw a curveball into those efforts, both with supply scarcity and a desire to effectively stave off threats.
“Supplies can be hard to get, and their prices have increased exponentially,” Govoni says. “Practices are just really taking a hit from all these supplies. For many practices, the concept of being green, or being ecologically responsible, is probably not at the front of their minds.”