This question was submitted by a general dentist: What is the most responsible and efficient way for dental offices to clean an operatory between patients and what disinfectants should we be using and where?
Drs. Nita Mazurat, from the University of Manitoba, and Suham Alexander provided a quick initial response.
This is probably the most frequently asked question by clinicians dealing with infection prevention and control. As a matter of fact, the real question is “which disinfectant should I use in my office?” The answer would be much easier, if there wasn’t such a wide variety of products offered on the market. However, the reality is that there are as many alternatives as there are disinfectant producing companies and, to further confuse matters, the product formulations are diverse. Clinicians want fast, cheap, and effective solutions and, as the adage goes, you do very well, if you get to choose 2 out of those 3 qualities!
One overlying principle is the use of products which claims have been validated. Since there is no practical way for the dental team to determine the effectiveness of the disinfectant used for patient contact surfaces, clinicians have to rely on a number of aspects to trust that the product will prevent cross-contamination to patients and oral healthcare providers. In Canada, the Drug Identification Number (DIN) attached to the product guarantees that the product meets Health Canada’s Food and Drugs Act standards.
The Centers for Disease Control and Prevention (CDC) recommends that an “intermediate-level disinfectant should be used when the surface is visibly contaminated with blood or OPIM (other potentially infectious material).” Since dental care usually involves transparent saliva spatter that is difficult to spot on surfaces, an intermediate-level disinfectant, also known as a tuberculocidal-level disinfectant, should be routinely used on clinical contact surfaces, including countertops and dental unit surfaces. This eliminates the uncertainty around whether or not the surface has been effectively cleaned, if and when it is contaminated with body fluids. That leaves one downside: the use of a more costly intermediate-level disinfectant when in fact a low-level disinfectant could have been used instead. Nonetheless, considering the amount of time required to decide which disinfectant to use certainly offsets the cost of the appropriate product, resulting in confidence that no error in judgement was made.
Another principle to consider is that to be effective, products, including disinfectants, must be used according to the manufacturer’s instructions. This includes, but is not limited to, the product shelf life, dilution, temperature (avoid freezing for example), application method, and product contact time with the surface to be effective, the latter being a critical aspect of disinfectants. Therefore, the surface must be free of any organic and any inorganic substances that would prevent the disinfectant from coming in contact with microorganisms on the surface that is being disinfected. By using barriers, the amount of time spent removing organic and inorganic materials is decreased. Furthermore, CDC states “after removing the barrier, examine the surface to make sure it did not become soiled inadvertently. The surface needs to be cleaned and disinfected only if contamination is evident. Otherwise, after removing gloves and performing hand hygiene, DHCP (the dental health care professional) should place clean barriers on these surfaces before the next patient.” Most offices perform this procedure and routinely disinfect the surface prior to placing a clean barrier, always assuming that the barrier was breached. However, the difficulty in following the CDC’s comment lies in the nature of saliva being transparent and undetectable making the term “contamination is evident” less than an ideal measuring stick.
It is important to reiterate and over emphasize the importance of following the manufacturer’s instructions on the use of products (IFU or Instructions for Use). Most dental chairs manufacturers do not recommend the use of chemical disinfectants on the leather or naugahyde material of the patient chairs, the operator’s, and the assistant’s stools, preferring the use of an (antimicrobial) detergent and water.
When purchasing countertops, consult the dental office designer who is typically familiar with the use of countertop materials as well as the need to routinely use disinfectants. If available, follow the instructions from the countertop manufacturer. There is probably no disinfectant on the market that will effectively preserve the countertop color and sheen while subjected to the known rigors of disinfection in a busy dental office.
The other area of disinfection is the laboratory. Generally, once laboratory items (impressions, crowns, wax rims etc.) are thoroughly rinsed, they should be immersed in a 1/10 dilution of sodium hypochlorite (5% or 5.25%) solution freshly made daily, or thoroughly sprayed with same solution and left in contact for 10 minutes. This is a cost effective way to disinfect almost all laboratory items. Manufacturer’s instruction must be followed since not all alginates can be immersed. After 10 minutes, lab items must be rinsed. Crowns can also be sterilized in a regular steam sterilizer process, but time is generally an inhibitor factor.
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