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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.
It’s important to leverage infection control investments for dental practices to make sense now, and in the future.
There are a lot of variables that go into selecting the right infection control products and equipment. Finding the right equation that balances those variables is a delicate formulation, one that factors in such issues as how the item is to be used, the practice’s need, and the existing environment. Ensuring that the right balance is struck can ensure that the practice invests in the best products that will last—and function properly—for a long time.
“This is a great time to have this discussion,” Karen Daw, “The OSHA Lady”, speaker and consultant, observes. “I’ve looked through dental school yearbooks that showed clinicians in HAZMAT suits, and every surface—including walls—were covered in plastic during the HIV/AIDS pandemic. Then, as more was known about the virus, some of these protocols went away. But others stuck around and are still practiced to this day. Can you imagine working in a patient’s mouth without gloves on today? My orthodontist was a smoker! How do I know this? Because I could taste the nicotine during an adjustment. Now we can’t imagine a world where this was even possible.”
Be Aware of What You Have, Need
As with so many things, the best place to start is by being cognizant of what you already have and what you need. Being mindful of your existing environment can help prevent a purchase that you may not be adequately prepared to support.
“A lot of times, when I look at infection control choices, I start out with saying, ‘Is the device or the equipment or the product able to be sterilized with my current system of sterilization?’” Dr. Douglas Risk, DDS, says. Risk is the Compliance Manager and private practitioner at Tidewater Dental in Southern Maryland, serves on the Executive Board of Directors for OSAP, is a Diplomate of the American Board of General Dentistry, and is a Fellow of the International College of Dentists.
“In other words, would I be able to sterilize X device in the cycle of my autoclaves that I normally use? If it says, ‘dry heat only’, and I have a steam autoclave, and I don’t have a dry heat sterilizer, I could be up against a $1,500 purchase. I need my device to work well with my existing processes. That’s key.”
That doesn’t mean that it isn’t worth investing in a new piece of reprocessing equipment should a new device make dentistry better.
“There’s a lot of times when you would look at a piece of equipment and say, ‘Yeah, this is going to make my practice more efficient,” Risk observes. “I can now do single-visit crowns or some other type of more efficient system—maybe increase my profitability or the patient service that I can provide. And, yes, it would be worth it to buy that new sterilization unit. We did that in the military with a scanner. It’s a sleeve that goes on the CAD/CAM scanner, and the reprocessing instructions included dry heat sterilization. So we bought dry heat sterilizers for the clinics that got that device. It was worth it, because then we could do a lot more of the short-turnaround crowns. We could do a lot more tooth-colored restorations that would replace what we would normally do in amalgam for full coverage restoration. This was an example where the benefits extended past patient care and efficiency, and benefitted the environment as well.”
Back to Basics
There’s no lack of cutting edge, high-tech equipment in the dental world. However, investing in such gear is not always necessary.
“Not everyone is in the position to afford a big-ticket infection control item to address COVID,” Daw observes. “For that reason, it’s important to return to the hierarchy of controls to determine what can we do that is within our control. For example, can we screen patients and prevent sick ones from coming in? Yes! Can we create administrative policies, like non-punitive sick-leave and educate patients and team members to perform proper hand hygiene, don facial coverings and practice social distancing? Absolutely! How about utilizing high-volume evacuators and dental dams? Yes and yes! These are examples of elimination, work practice and engineering controls that can be used now and always. Then, at the bottom of the hierarchy of controls, we introduce PPE to protect us. But it amazes me how many practices do not have a PPE certification on file to meet the OSHA requirement.”
A wise strategy, Daw suggests, is to have a mastery of the basics.
“Perhaps the best way to futureproof our IC is to ensure that we have a solid foundation,” she says. “Sometimes it’s good to go backwards to go forwards. Let’s look at the non-pandemic investments in infection control that we can make. Training, and maybe even working with a consultant, to make sure the safety program has a nice solid foundation. How about implementing cassettes and instrument washers to minimize risk and enhance workflow? Investments in instrument reprocessing, water quality, good sterilization equipment, solid infection control in the treatment rooms, gloves, masks—the need for these will most likely never change and will carry us through the next pandemic.”
Single-Use or Sterilizable?
Being mindful of whether or not a product can be reprocessed is another place where practices can avoid missteps with their purchases. That is, is the item being purchased a single-use or sterilizable item?
“The other thing that I like to see in a device or product is single-use or unit dose,” Risk says. “If they can’t be reprocessed or sterilized or cleaned adequately, they should be labeled single-use. If manufacturers say it’s single-use, they should be priced for single-use, and the FDA should support single-use on that device. For instance, most of your rotary instruments—burs and diamonds and so forth—they cannot, according to the FDA, be cleaned adequately to be reprocessed. Therefore, those items are deemed single-use by the FDA. Whether the manufacturers have deemed them single-use or not, that is the question. Do they have reprocessing instructions that have been validated by a third-party, to say, ‘Yes, this device can actually be cleaned well enough to render it sterile in a sterilization unit.’?”
Being aware of the distinction puts the practice on notice as to whether or not the item requires more care than they anticipated.
“There are a lot of times when we look at a device and look at the claims and say, ‘Oh, gee, that sounds great. I’ve got a place in my practice for that’,” Risk says. “And then we don’t go back and say, can this be cleaned? Can it be sterilized? Is this a single-use item? What’s the expense trail of that item? Does this require quite a bit of maintenance? Does it require calibration? Do I have to hire somebody to calibrate it? Or does it have an initial cost and then per-use costs for products or filters or some kind of other device that is a companion with it to to put it to use? So, sometimes there are hidden costs, sometimes there’s equipment that we can’t clean or can’t sterilize. Some equipment and devices are very expensive, such as handpiece motors, sold separately. Clinicians may wipe a device that should be sterilized because of cost. The right thing to do is to buy enough devices to sterilize each piece intended to touch mucous membranes, or are used intraorally, in providing dentistry.”
Regrettably, many practices tend to make the same sorts of mistakes when it comes to purchasing infection control items.It can be easy to be blinded by the lofty promises of a new device, but don’t let the smoke and mirrors of a sales pitchmask the true functionality and operation of a new purchase.
“Sometimes they need products that look really great, or the claims are exactly what they need,” Risk says. “And then they find they can’t either afford to purchase the dedicated maintenance items or the dedicated supply items, or they just can’t clean it, because that item requires a different type of sterilizer. We’ve seen that a lot when I was at the Dental Evaluation & Consultation Service in the Air Force. Folks would buy something, then they were up against a survey from the Joint Commission, and they didn’t have the ability to follow the manufacturer’s instructions for routine reprocessing. So, they got into a little bit of an issue trying to put that process together for an inspection or for a survey.”
That has also been an issue during the COVID pandemic—in their haste to mitigate the virus’ dangers, too many practices are rushing to buy products with unsubstantiated efficacy claims.
“A lot of times, with COVID coming up and some of the things that we’re looking at with a little bit more of the airborne pathogen challenges that we have, a lot of people are using air cleaners, and some of these items have claims that they’re going to clean your air or do something that sounds really good,” Risk says. “But the clinical evidence sometimes is missing. They say that they can clean the air, passing the air through a UV filter or high-efficiency filter. And for that filter, or that light, or that mechanism to actually clean the air, and validate it in the speed that is required to clean the air in a dental operatory, is just difficult. So, somebody says, ‘I’ve got high-efficiency air conditioning system and it sucks that air up and passes it through a filter 10 or 12 times per hour,’ is that device capable of filtering that much air through that kind of filter? There are a lot of products out there; there are great products, but we need to make sure that sufficient clinical data exists.
“Saying that, ‘Yes, what you’re claiming and the speed that you’re claiming you can pass all this air through a filter, but is that device capable of filtering that much air through that kind of filter?’ You need real world experience or real world data concerning the actual cleaning of the air of viruses.”
“Like you, I’ve seen non-stop articles touting ultraviolet germicidal disinfection, hypochlorous acid or other viricidal foggers, roll-away HEPA filtration units and extraoral suction systems,” Daw adds. “The challenge has been seeing which are necessary and effective, given the current situation. And while some have the data to prove this, will this be relevant for the next infection control challenge? Regardless of what people are purchasing, it’s good to do the homework (aka research) before making investments. Like the title of this article, we want to make sure it will be good for now, and good as we move forward, too. Keep an eye out on the latest technology and continue to learn about what’s new.”
For all the hype surrounding current high-tech equipment, sometimes older, tried-and-true methods are best.
“We’re talking about high-tech devices, when sometimes a lower technology device would work just as well or better,” Risk says. “For instance, a rubber dam. Going back to that for routine operative or routine crown and bridge for a lot of the processes, other than just root canals, would isolate the operative field a lot better than some of these other devices that don’t actually isolate the area, but tend to use high-volume evacuation throughout the mouth. So sometimes a lower technology is just as good or better than a higher technology.”
No one wants to buy the wrong product or piece of equipment, but taking the time to ensure the right environment exists and the right product is selected will no doubt save the practice money and, best of all, time.