The surface disinfectant challenge.
It is impossible to achieve 100 percent sterilization of surfaces in any dental operatory. Unlike small dental instruments, large pieces of equipment cannot be moved and heat sterilized; however, dental professionals can achieve high levels of disinfection with the use of proper aseptic techniques and the use of barriers and surface disinfectants. The risk of disease transmission is significantly lowered when this combination is used.
There are a number of things to consider when choosing a surface disinfectant. First, a thorough understanding of the current CDC infection control guidelines for dentistry is needed. Every dental office should keep a copy of the most current guidelines in a location easily accessible to all members of the dental team. (1) A copy of the guidelines is online at www.cdc.gov/mmwr/preview/mmwrhtml/rr5217al.htm. The guidelines can be somewhat difficult to read and understand. The Organization for Safety and Asepsis Procedures (OSAP), a great resource for dental professionals, has an easy-to-read workbook that helps dental professionals understand the guidelines in a clear and concise manner. The OSAP workbook, From Policy to Practice: OSAP's Guide to the Guidelines, helps dental professionals understand how to apply the CDC guidelines in clinical practice. (2) OSAP also has a Web site that contains additional infection control resources (www.osap.org).
A second item to consider when choosing a surface disinfectant is the surface or item to be disinfected. Some surfaces or items require disinfection, whereas others require sterilization. Disinfection chemically destroys most microorganisms on objects or items but does not destroy all bacterial spores. Sterilization, on the other hand, uses heat or chemicals to kill all microorganisms including spores. (2) Dental professionals must distinguish between environmental surfaces versus patient care items when selecting disinfection or sterilization.
Critical and semi-critical patient care items must be heat-sterilized prior to use in patient care. Critical items include any objects that penetrate soft tissue or bone and have a high risk of transmitting disease. Dental hygiene instruments, burs and surgical instruments are some examples of critical items. Semi-critical items include objects that touch mucous membranes but do not penetrate and have a lower risk of disease transmission. Examples include mouth mirrors and handpieces. If semi-critical items are not heat-tolerant (plastic or rubber items), they can be immersed in a high-level disinfectant for three to 10 hours to achieve sterilization. Most patient care items today can be heat-sterilized on a special cycle for plastic and rubber objects. Non-critical items such as stethoscopes and blood pressure cuffs touch only intact skin and have the lowest risk of transmitting disease. These items can be disinfected rather than sterilized. (2)
Environmental surfaces in the dental operatory have the lowest risk for transmitting disease and are considered non-critical. Although the risk for disease transmission from environmental surfaces is low, we still need to lower it as much as possible through the use of disinfectants or barriers, There are two types of environmental surfaces in the dental office: housekeeping surfaces and clinical contact surfaces. Housekeeping surfaces such as floors and walls are not routinely touched during patient care and can be cleaned rather than disinfected at the end of the day. Clinical contact surfaces such as light handles, switches and chair controls are routinely touched and easily contaminated. (2), (3) During the course of treatment, dental professionals adjust the chair and light handles, hold high- and low-speed suction devices, and touch other surfaces such as cabinetry with gloved, contaminated hands. Contaminated dental instruments can also touch various surfaces, thus indicating the need for surface disinfection or barriers.
There are two methods for handling clinical contact surfaces: use of disposable surface barriers or use of a surface disinfectant. Neither is superior; both are acceptable. A combination of both is the best in most situations, (3) Each dental office must decide which method to use based on the needs of that particular practice. There are pros and cons with each method.
Disposable surface barriers are impervious plastic covering materials that can be used for handling clinical contact surfaces in the operatory. Barriers are placed on clean surfaces at the beginning of the day and must cover the entire surface. (2) After patient care, it is necessary to carefully remove barriers and simply replace with a new one. There is no need to disinfect the area covered by the barrier unless it has been contaminated, (2) Use of barriers can decrease operatory turnaround time, and they are good choices for hard-to-clean surfaces. Barriers are one-time use items and must be replaced between patients. These items include chair covers, headrest covers, tri-syringe covers, light handle and light switch covers, and covers for high- and slow-speed suction tubing.
Barriers can be used on clinical contact surfaces alone or in combination with surface disinfectants. Use of personal protective equipment (PPE) is necessary when performing disinfection procedures. Surface disinfectants must be used on clean surfaces to achieve adequate disinfection with the spray-wipe-spray method. (4) The first "spray" is to clean the surface of blood or any other potentially infectious material; then the surface is thoroughly wiped. The second "spray" leaves the surface moist for a manufacturer-specified contact time to achieve disinfection. (2) Contact times vary among manufacturers and are usually between three and 10 minutes. Check the manufacturer's label for contact times. Some products are a one-step cleaner and disinfectant, in which the surface can be sprayed and wiped and then left moist for the product's contact time. Pre-moistened wipes are an alternative to the spray-wipe-spray method and are growing in popularity due to their easy use. Label instructions must be carefully followed with pre-moistened wipes. Some wipes are disinfectants but not cleaners that require a separate pre-cleaning step. They may be effective only on small surface areas (less than three feet), so the label should be checked carefully. (2)
There are pros and cons to both barriers and surface disinfectants. The pros of using barriers include quick operatory turnaround time, ease of use, protection of surfaces that are difficult to clean and no exposure to chemical agents. Some of the cons are the cost of the impervious plastic material and increased office waste; in addition, they may not be aesthetically pleasing. The advantages of using surface disinfectants are lower costs, less waste and staff compliance (procedures are familiar); plus, disinfectants do not affect aesthetics. The cons include exposure to chemicals (irritancy), contribution to environmental pollution, requirements for proper handling and increases in operatory turnaround time. (3) There is no evidence to support presoaking of gauze squares in disinfectants in covered containers. Early anecdotal evidence indicates that the potency of the disinfectant might be reduced and that evaporation can occur. (5) Carefully follow the manufacturer's directions for use with any disinfectant.
A third and most important consideration to be evaluated when choosing a surface disinfectant is its level of efficacy, Surface disinfectants are categorized into three levels: low-level, intermediate-level and high-level. High-level disinfectants are not used in dental offices as surface disinfectants, so they will not be discussed. They are often used for long-term immersion of heat-intolerant items to achieve sterilization. Product labels will not state "low-level" or "intermediate-level," so the dental professional must be able to decipher the level based on the product's label claim. This is the tricky part!
Both low- and intermediate-level disinfectants will carry the label claim "hospital disinfectant." This means that the product is effective against three test organisms; Salmonella choleraesuis, Staphylococcus aureus and Pseudomonas aeruginosa. Some low-level disinfectants may kill HIV and hepatitis B virus (HBV) if stated on the label. They can be used as a cleaner on surfaces that are not visibly soiled with blood or other potentially infectious materials. (2) Low-level disinfectants generally are useful for cleaning housekeeping surfaces and clinical contact surfaces that are not contaminated with blood.
Intermediate-level disinfectants include all of the same properties as low-level disinfectants but are also tuberculocidal. This means that the product is effective against the hearty test organism Mycobacterium tuberculosis. Intermediate-level disinfectants can be used on both housekeeping and clinical contact surfaces that are soiled with blood or other potentially infectious materials. (2) Most of these disinfectants have labels claiming them to be bactericidal, fungicidal, virucidal and tuberculocidal. As long as the label claims tuberculocidal activity, you can be assured that it is an intermediate-level disinfectant. They can be a cost-effective way to achieve disinfection with a single product.
You may ask, "Why even use low-level disinfectants?" The answer to that is complicated. Low-level disinfectants are often used on housekeeping surfaces in hospitals or medical clinics that are not contaminated with blood. The dental treatment environment is unique in that blood and other potentially infectious materials are generated, and these produce aerosols that can easily contaminate clinical contact surfaces. Compared to other treatment environments, dental treatment rooms generally contain more clinical contact surfaces and splatter (blood or other potentially infectious material) that may not be visible to the naked eye. Because each practice is unique, dental professionals must assess the individual needs of the practice. (6) Some practices may provide services that generate more contaminated splatter than others; the decision to use products must be based on need. The most important point to remember is to read the label on surface disinfectant products carefully.
Dental professionals should have a general understanding of a surface disinfectant's classification or type based on its complex chemical formula. The classification includes the chemical compound of the family to which it belongs. Understanding these classifications can be difficult. It is more important to understand the product's level of efficacy (low- or intermediate-level) than its classification. There are four standard types or classifications: chlorine-based products, phenolic solutions (water- or alcohol-based), iodophors and quaternary compounds. (2), (4), (7), (8) Chlorine-based products include chlorine dioxide or sodium hypochlorite (household bleach). These products have a broad kill spectrum but, often, a limited shelf life. Household bleach is no longer recommended as a surface disinfectant because it is not Environmental Protection Agency (EPA) registered. (6) Phenolic solutions can be water- or alcohol-based and are identified with prefixes and suffixes such as "phenol" or "phenyl." Iodophors are less irritating to the skin and usually contain the letters "iodi" or "iodo." Quaternary compounds are not corrosive and have a lower kill spectrum. Always check the label to determine if the product is ready-to-use (RTU) or if it needs to be mixed. If it needs to be mixed, make sure to use the correct dilution ratio indicated on the label. Table I lists various product names including their classification.
Table I. Examples of Surface Disinfectants Classification Brand Name Manufacturer Level Chlorine-based Chlorox Germicidal Harry J. Bosworth Low Wipes[R] Company Phenolics: Birex SE Biotrol Intermediate Water-based Concentrate[R] International DisCide Foaming Palmero Health Intermediate Cleanser[R] Care ProSpray[TM] Certol Intermediate International Phenolics: Coe Spray II[TM] GC America Intermediate Alcohol-based DisCide Spray[R] Palmero Health Intermediate Care Iodophors IodoFive Surface Certol Intermediate Cleaner[TM] International Quaternary CaviCide Spray[R] TotalCare/ Intermediate Compounds Pinnacle/ Metrex CaviCide Wipes[R] DisCide ULTRA Palmero Health Intermediate Spray[R] Care DisCide ULTRA Wipes[R] GC Spray-Cide[TM] CG America Intermediate Opti-Cide-3 Micro Scientific Intermediate Spray[R] Industries PDCare Wipes[TM] Patterson Dental Intermediate Sanitex Plus Crosstex Intermediate Spray[R] International Sanitex Plus Wipes[R] Sani-Cloth PDI International Intermediate Wipes[R] This is a partial listing of various surface disinfection products commonly used in the dental office. Chart adapted with permission from OSAP's Surface Disinfection Chart- 2009. OSAP does not endorse any product or company.
One of the final things to verify when choosing a surface disinfectant is that the product contains an EPA registration number. All hospital disinfectants must carry an EPA registration. A disinfectant also should be easy to use, with a reasonable contact time and shelf life. It should have clear instructions and be non-irritating to the staff using it. (2) Purchasing one product for cleaning (low-level) and another product for disinfecting (intermediate-level) can result in higher costs and increased inventory. Choosing intermediate-level disinfectants (those that have cleaning and disinfecting properties together) will save time in operatory turnaround, as well as money by keeping inventory low.
The needs of each dental office are unique. There is no one "correct" product for surface disinfection. Dental professionals should be familiar with the CDC guidelines and how they affect daily practice. The bottom line is to read product labels carefully and choose the appropriate products for your office. The needs of our clinic resulted in a decision to purchase an intermediate-level surface disinfectant that both cleans and disinfects. Our clinic currently uses a combination of barriers and surface disinfection due to the high volume of patients receiving care. Utilizing this approach has been an efficient and cost-effective method for our clinic.
(1.) Centers for Disease Control and Prevention. Guidelines for infection control in dental healthcare settings 2003; 52(RR-17): 1-66.
(2.) OSAP. From policies to practice: OSAP's guide to the guidelines. Workbook. Annapolis: OSAP, 2004.
(3.) Palenik CJ. Environmental surface asepsis. Dent Today 2005; 24(9): 122, 124.
(4.) Molinari JA, Palenik C3. Environmental surface infection control, 2003. Compend Contin Educ Dent 2004; 25(1): 30-7.
(5.) OSAP, 2003 CDC Guidelines offer more choices for managing operatory surfaces. J Calif Dent Assoc 2004; 32(11): 913-6, 918.
(6.) DePaola LG. Infection control and dental practice: frequently asked questions. Compend Contin Educ Dent 2004; 25(1): 38-42.
(7.) Springthorpe S. Disinfection of surfaces and equipment. J Can Dent Assoc 2000; 66(10): 558-60.
(8.) Miller C. Chemical products confuse users by claiming varying capabilities and contact times. RDH 1996; 16(11): 40, 56.
By Kandis V. Garland, RDH, MS
Kandis Garland, RDH, MS, is assistant professor and health and safety coordinator in the Department of Dental Hygiene at Idaho State University (ISU) in Pocatello. Her research, which she presents nationally, focuses on infection control. Professor Garland is also clinical coordinator for first-year students in the ISU baccalaureate dental hygiene program.
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|Title Annotation:||clinical feature|
|Author:||Garland, Kandis V.|
|Date:||Jan 1, 2010|
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