Technologies that have been advancing in the past few years can be utilized in the practice for best infection control practices.
When one thinks about “Technology”, the mind tends to go to the computers that are on every desk or the smartphones that are in everyone’s pockets but, technology is more pervasive. Even something as humble as the kitchen toaster isn’t the same thing that it was 10 or 20 years ago. The same is true of technology in the dental office, including infection control equipment.
It’s easy to understand why the equipment used for infection control is specialized – it performs very specific, exacting jobs.
“Sterilization is complex,” Jackie Dorst, RDH, BS observes. Dorst is an infection prevention consultant and speaker. “Very often it’s assumed to be akin to a Shake-and-Bake-type of procedure in dental offices. It’s very complex and it does require training and knowledgeable team members in the sterilization room, or errors and oversights can be made. I’ve actually heard dental assistants refer to the ultrasonic as the shaker and the sterilizer as the baker. We shake them in the instrument ultrasonic, and then we put them in the sterilizer to bake them, and then we take them out and reuse them. But, It’s much more complex than that, and there is a lot of new technology that is coming into the sterilization room for instrument reprocessing that both improves the process, and actually helps us with the record keeping.”
“There are a lot of pieces of equipment that need specialized types of sterilization,” Douglas Risk, DDS, says. Dr 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. “For instance, some of the scanner sleeves should be dry heat sterilized, and very few dental offices have a dry heat sterilizer.”
Some pieces of equipment may seem reasonably straightforward but are misunderstood. For instance, it may be easier to assume that instrument washers are little more than household dishwashers, but they are far more complex. Not understanding how they function and how they are used can lead to infection prevention problems.
“Instrument washers are often referred to as thermal disinfectors, because of the high water temperature and water pressure, plus a disinfecting chemical can be added to the rinse cycle,” Dorst says. “When the instruments are removed from an instrument washer the instruments are dry and ready for sterile packaging [which is] a big benefit and time saver over ultrasonic cleaning. After the ultrasonic cleaning, the instruments must be rinsed with water and then laid out and dried until they’re completely dry before they are put in sterile pouches. In many dental offices, because they’re in a rush to put those instruments through in a short time, those instruments are packaged wet inside the pouches, and that contributes to tearing of the pouches, leaving open portals for microorganisms to get in.”
But that’s not all.
“Autoclaves sterilize with steam,” Dorst says. “The steam must touch the surface of the instruments to sterilize them. It’s not just that the instruments get hot. The steam must touch the surface of the instruments. Steam sterilization temperature are normally between 250- and 273-degrees Fahrenheit, 18 to 21 pounds of pressure per square inch, and an exposure time of at least 3 minutes. Sterilization is a very complex process, and unfortunately, that’s where training is not always provided to new team members when they come into the office. The most frequent cause of sterilization breaches is a lack of knowledge and training.”
Given the nature of this equipment, its purchase and use may seem intimidating, but it doesn’t have to be.
“If there any piece of equipment that you’re considering purchasing, you need to read the directions for use and get an idea of the intent for use or the design of the product to make sure it’s compatible with the rest of the office equipment,” Dr Risk advises. “A lot of times we’ll buy something because a sales rep or manufacturer says, ‘This is the greatest thing. You need to use this.’ And then it turns out to be a different voltage or a different type of thing, or it can’t be cleaned. Those are the kinds of things which make it difficult to integrate into a practice. The piece of equipment may, indeed, be the greatest thing and you may need it, but compatibility needs to be considered in order to integrate it into the practice.””
Finding out whether a piece of equipment is best for an office necessitates some legwork on the practice’s part, and there is rarely a single source for the best suggestion.
“I don’t think there is one best place,” Dr Risk says. “I think you need to listen to all advice, and when you just can’t stand not having it, that’s when to buy it. So, what I would say is that you don’t go out and buy a piece of equipment the first time you hear about it. You go back to your practice, and you ask yourself, ‘Is this going to integrate or make my practice better?’ You research that piece of equipment and things like it from all sorts of sources – and you can use any resource that you’d like; I would prefer that you use all of them rather than just the ones you like. And then start digging into the literature, start finding experts that know the literature well and figure out whether this piece of equipment is reliable, whether it has made other people’s practices better.
“Then, what’s the learning curve? Ask those kinds of questions,” he continues. “So that you end up with a good idea before you even integrate that piece of equipment into a practice, how much the workload will change, or your workflow will change. A lot of times you can go to a manufacturer, and they can overhaul your office, but then they expect you to work exactly the way they say you should work. And then sometimes that’s not the way you want to work. So, it’s a little bit difficult, once in a while, to do that kind of overhaul.”
Depending on the size and volume of the practice, an instrument washer can help save time and money.
“Instrument washers are usually advantageous for large practices that sterilize a large volume of instruments and use cassettes,” Dorst observes. “You really need to be a cassette user to efficiently use an instrument washer. So, larger practices sterilizing a large number of instruments find that it’s advantageous for them to install an instrument washer. The initial investment cost is greater than an ultrasonic, but the time saved compensates. After replacing an ultrasonic with an instrument washer, I've had team members come back to me and say, ‘We never want to go back to ultrasonic instrument cleaning!’”
It’s easy to be overwhelmed by some equipment, even those pieces that seem to be in every practice.
“Almost every office has a sterilizer and almost everyone working that sterilizer has probably not read the directions for use in a little while,” Dr Risk observes. “So, if I had one piece of advice, I would ask everyone that uses a sterilizer to open the book and go through it and read some of the information that’s in there about whether the packs go plastic up or plastic down, how you load it, what the parameters are for drying and sterilizing, and things like that. Look at your normal workflow and see if it actually is a hundred percent following the directions for use.”
Another piece of misunderstood equipment sits right next to that sterilizer.
“I would do the same thing with the ultrasonic cleaner,” Dr Risk says. “How long should that ultrasonic cleaner be on with instruments in it with the lid closed before the action of the solution has had its chance to work, because a lot of people put instruments into an ultrasonic cleaner while it’s running, and either it’s on a timed cycle or the instruments inside of it have already gone through a part of a cycle.”
Sign of the times
The COVID-19 pandemic led practices to embrace new technologies to mitigate infection concerns. Not every idea was a good one.
“During the pandemic, one of the innovative strategies that dental offices pursued was to just spray disinfectants into the air,” Dorst says. “And this is not an approved method by the Environmental Protection Agency (EPA). You can imagine what it meant to spray any of these toxic chemicals that are designed to kill bacteria, virus, or fungus in the air. Oh my gosh, that would require full personal protective equipment (PPE). And you know, you’d need to be using one of those half-face chemical respirators, similar to what a HAZMAT team would come in with. So, at this time, that’s not an approved technology to do spraying of disinfectants into the air.”
As with any technology, however, anything new must be used properly and in accordance with the manufacturer’s directions for use.
“There is a lot of technology [that has come] from the COVID-19 pandemic especially with aerosols and again, I think people should look at all the literature,” Dr Risk says. “I think they should, if they decide to buy a product, I think it should be based on a need or a strong desire to accomplish what that piece of equipment does. And then that piece of equipment has to be not only performing well, but used in the practice so that it can do whatever it says it’s going to do. So, if you’re expecting to do an entire office filtration system with UV disinfection, you need to allow that UV disinfection to clean the air however that system is going to clean the air. In other words, if I’m in operatory 1 and the UV filter is down by operatory 6, the air has to go from my operatory all the way down to the UV filter and back before it’s clean. You can’t stick that filter in and then run that room a hundred percent with no time to turn the air over. If you’re using some kind of filter system that’s close to the operatory space, then those filters have to be changed on schedule, according to the directions for use. You can’t set something up and then not maintain it.”
Technology, whether it’s in the kitchen or the dental practice, must be understood for its effective use. That necessity is underscored even more when it plays such a vital role in the practice’s safety.