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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Digital Esthetics. 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.
Taking the time to brush up on some infection control basics can keep dental practices from becoming their own house of horrors.
Dirty torture implements.
Garments splattered in blood.
Monsters lurking in the shadows.
These aren’t just seasonal fixtures at the local haunted house, they could just as easily be the chilling terrors at a local dental office. Too often, simple mistakes and oversights can turn the dental practice into its own house of horrors.
Instruments are, certainly, often already regarded by patients as torture devices, but what’s even more concerning is that those implements of pain could be dirty, and their contamination can come from many sources. For instance, the practice may not be packaging the handpieces and instruments that are not destined for immediate use.
“Sterilized handpieces and instruments that are not going to be used immediately upon removal from an autoclave must not be placed into drawers for future use,” Mary Bartlett, President of SafeLink Consulting, says. “They must be packaged properly in either sterilization pouches or in wrapped cassettes.”
Even those items that should clearly be disposed of can sometimes sit around well beyond when they need to be discarded.
“Each sharps container has a line on it indicating when it is considered ‘full’,” Bartlett says. “Using the container beyond that indicator can result in a sharps injury. Staff needs to be trained to watch for this hazard.”
Failing to identify dirty instruments can lead to their being accidentally used on another patient.
Most dental professionals might think that they would never make such a mistake, but Bartlett warns against such.
“I know anyone reading this will say that there’s no way that could happen, but believe me, it can,” she observes. “Dirty instruments should not be removed from the treatment room and placed into another area if they are to be used again on the same patient. Avoid any kind of ‘holding’ area. If instruments must be removed from the treatment room, then they must go direct to sterilization. If additional instruments are necessary for the patient, then use sterilized, unopened instruments.”
Leslie Canham, an expert in dental Infection Control and Safety, shares that missteps in basic sterilization steps can lead to breaches, patient notification, and infection transmission.
“Last year, at a school-based children’s dental clinic, over 1,200 children were potentially exposed to unsterile instruments,” she recounts. “Letters were sent to their parents urging them to have their children tested for Hepatitis and HIV. Can you imagine if you got that letter? The reason was for the notification was that the dental clinic workers did not sterilize handpieces. Instead, they wiped them with disinfectant. All handpieces and handpiece components must be heat sterilized according to CDC Guidelines and most states’ Dental Board infection control standards. Even if the dental team used plastic barriers and disposable prophy tips, the handpieces still go into patients mouths and must be heat sterilized between each and every patient.”
Another issue is not properly noting on the sterilization pouches or wrapped cassettes the date, time, or cycle number of which sterilizer was used.
“The purpose of these notations is to assist in determining which instruments must be re-sterilized in the event that the sterilizer failed,” Canham observes. “If there are no notations of this information, then every pouch and wrapped cassette must be re-cleaned, re-packaged, and re-sterilized. This could be a difficult situation to face for a practice that’s very busy and doesn’t have enough sterilized instruments to use.
“Every dental practice is supposed to spore test their sterilizer at least weekly to make sure it is working,” Canham adds.
The issue is that if a “Failed” spore test comes back, it may be too late. Contaminated instruments may already be placed into service.
“If you mail your spore test to a third-party testing service—which is what the majority of dental offices do—it takes a few days to get there by mail, be processed, and have results,” Canham says. “You may not find out until a few days later that one of your sterilizers isn’t working.”
One remedy would be to use an on-site spore testing kit where results can be obtained in as little as 24 minutes. (One example is the new 3M Attest Mini Auto-reader 490M.)
A dental practice might also consider using chemical integrator strips, which can provide results with 99 percent accuracy. While they don’t replace spore testing, they can provide confidence that the sterilizer is working correctly on a daily basis.
Improper use of the sterilizer is the source of other frightening events, as well. That can be avoided by observing the manufacturer’s direction for use.
“You would be surprised to know how frequently I find that overloaded sterilizers or wrong type of sterilization pouch or wrap are being used,” Canham observes.
Practices often rely on chemical indicators on the pouch or wrap to tell them whether or not pouches have been treated. However, they shouldn’t rely solely on color change.
“The color change doesn’t mean instruments are sterile,” Canham adds. “Only spore testing will give you the information that you have, indeed, achieved sterilization. The color indicators tell you that they went through the process. So, everyone who opens that sterilizer chamber should look to make sure that the indicator color change has occurred before they remove those instruments for use.”
But that responsibility shouldn’t stop with the person who takes the instruments out of the sterilizer.
“The next person who actually takes those instruments out to the patient care area should verify—visually verify—that the color change happened,” she continues.
With something as important as instrument processing, an abundance of care and attention to detail are necessary.
“Dental staff is so accustomed to the sterilization pouches having an internal and external indicator that they forget to place a chemical indicator inside the wrapped cassette or other container,” Bartlett says. “The purpose of having both indicators is to ensure that the temperature reached an adequate range to indicate that internal and external temperatures have been met. Also, when the pouches are removed from the sterilizer, be sure to check both the internal and external indicators.”
If an autoclave is discovered to be compromised, immediate action must be taken.
“This autoclave must be removed from service immediately if a ‘Failed’ notice is received and the instruments that were processed during the period between the last Pass and the current date must be re-sterilized in a different autoclave,” Bartlett says. “The dental suppliers usually will provide a loaner, but that may not be as quickly as it’s needed.”
Another mechanism used to protect staff and patients can be another source of infection control frights. Mishandled personal protective equipment (PPE) poses a serious threat.
If we’ve learned anything from 2020, it’s that respirators may have to be reused, and properly storing them is critical.
“Because of the COVID-19 pandemic and the shortage of facemasks and respirators, some practices are having to ration respirators, such as the N95,” Bartlett says. “Usually, they are changed at the end of the shift, so if that is the case and they are to be re-used another day, then place them in a paper bag rather than a plastic container that would prevent air circulation.”
It’s not enough to have and properly maintain PPE; it must besuitably donned and doffed.
“CDC has issued guidelines for donning and doffing PPE in order to prevent cross-contamination of others,” Bartlett says. “Dentists and staff should refresh their knowledge of these steps in order to prevent cross-contaminating themselves and others. Because of the COVID-19 pandemic, the eye protection and facemask or respirator should not be removed in the treatment room.”
Scrubs may be determined to be PPE, and if so, should not be taken home for laundering, which is an issue that some staff members may not recognize.
“If staff is required to wear scrubs as a uniform and take them home to launder them, then they must be protected with an outer garment, such as a gown or lab coat, during patient treatment,” Bartlett says. “If they are worn without protective clothing over them during patient treatment or when performing tasks in the sterilization area, then they should not be taken home for laundering.”
Because of the pandemic, we may not see as many haunted houses this year, but taking the time to brush up on some infection control basics can keep the dental practice from becoming its own house of horrors.