This article originally appeared in Dental Assisting Digest e-newsletter. Subscribe to this informative monthly ENL designed specifically for the dental assistant here.
The two of us became friends after meeting at a dental conference. We bonded over our love of tapas and infection control, of all things! It’s common to hear educators, consultants, and dental professionals talk about the challenges of infection prevention as naturally as if they were discussing the weather at any Organization for Safety, Asepsis, and Prevention event (www.osap.org).
If you’re serious about safety in your dental practice, then membership with OSAP is a must! Drawing from our experiences as consultants and educators, we put our heads together and came up with a list of three common infection control breaches that we felt could use a little extra love and attention in dental settings.
All water is safe, right?
I was recently sitting in a restaurant and staring sadly into the bottom of my coffee mug, silently willing the server to acknowledge that I needed a refill. I noticed a brown buildup lining my cup that I could easily remove with my finger. This stain was similar to biofilm, which forms when bacteria attaches to moisture-rich surfaces. Of course, dental plaque is a great example of biofilm, as is that stone you pick up at the pond that feels slick. Biofilm develops on a surface over time and is difficult to remove. Unlike the caffeinated residue in my cup, biofilm can be dangerous and difficult to get rid of.
Because public water entering a building is safe, it’s easy to conclude that water coming out of the dental units is safe, too. However, the narrow tubing used in most dental units actually contributes to the formation of biofilm. In fact, these lines are the perfect breeding ground for bacteria. The Centers for Disease Control and Prevention recommends that dental unit water contain no more than 500 colony-forming units of heterotrophic bacteria per milliliter (500 cfu/mL). This is the equivalent of safe drinking water as set forth by the Environmental Protection Agency. The only way to know if your waterlines meet this standard is to test them. There are two methods for doing this—in the office or by using a mail-in testing service. The American Dental Association has a page dedicated to both types of waterline testing at ada.org/en/member-center/oral-health-topics/dental-unit-waterlines.
If the test results are greater than 500 cfu/mL, then the lines may need to be treated. This typically involves shocking the lines to kill bacteria immediately, or using a maintenance product that is labeled to reduce biofilm over time. If the practice is using a waterline maintenance product but there’s still biofilm in the lines, then the maintenance product may be ineffective.
However, if the test results indicate the water coming out of the ultrasonic scaler, air/water, and handpiece lines are under the threshold set by the EPA, then a maintenance product should keep safe water flowing. Some waterline maintenance products require monthly testing, while others require only annual testing. It is important to follow the manufacturer’s instructions for proper usage, monitoring, and testing frequency.
Is it spray, wipe, spray, or is it wipe, toss, wipe?
Here’s an easy example about disinfectants and sterilization of handpieces. We both love avocados. Each time we eat one, we clean the plate before running it through the dishwasher or some avocado is guaranteed to remain when the dishwasher is done. Similarly, environmental surfaces need to be cleaned of debris prior to disinfection, which then allows the disinfectant to reach and kill microorganisms.
Three levels of disinfection exist—high (not used on surfaces), intermediate, and low. Both intermediate level disinfectants (with a tuberculocidal claim and used to remove visible blood soil) and low-level disinfectants (with HIV and HBV claims) are registered with the EPA. Avoid store products that don’t have an EPA number on the label or are not hospital-grade.
Whichever spray or commercially-prepared wipe you use, follow the manufacturer’s instructions on the package. Read the label to determine if the product is a cleaner, a disinfectant, or both. Using the product in the right amount, dilution, or contact time is critical. Contact time is the amount of time the product stays wet on the surface of the item being disinfected. Some products need one minute, while others need three minutes or longer. If a disinfectant dries too soon it will not do its job. Making your own pre-made wipes by wetting 4x4 gauze squares with disinfectant is an off-label product use. Bleach contained in the squares reduces the effectiveness of the product, so always follow the directions.
Sterilize both handpieces and motors?
We follow a few online forums, and every so often there is a lengthy discussion about when, how, and which handpieces need to be sterilized. It’s common to see hygienists report that they only wipe down their handpieces with disinfectant. While we know that dental handpieces must be cleaned and sterilized prior to reuse, there seems to be ample confusion regarding low-speed motors and commonly-used attachments.
In 2016 the CDC issued a companion document to the 2003 Guidelines for Infection Control in Dental Health-Care Settings. It said in part, “Dental handpieces and associated attachments, including low-speed motors and reusable prophylaxis angles, should always be heat sterilized between patients and not high-level or surface disinfected. Although these devices are considered semicritical, studies have shown that their internal surfaces can become contaminated with patient materials during use. If these devices are not properly cleaned and heat sterilized, the next patient may be exposed to potentially infectious materials.”
So which handpieces should be sterilized? All dental handpieces and other devices not permanently attached to air and waterlines of dental units should be removed, cleaned, and heat-sterilized between patients. It is our responsibility to see that we understand, follow, and comply with the handpiece manufacturer’s instructions. Wiping down handpieces with disinfectant or the use of barriers is not acceptable. If your practice does not have enough handpieces to keep up with patient load, then the practice needs to order more.
There are many opportunities in dental practices to improve infection control, and this is just a snapshot of what we’ve seen in offices across the country. Remaining vigilant and educated can help you identify additional opportunities for enhancement. A solid resolve to do the right thing and a commitment to safety can make all the difference in patient health!
Joyce A. Moore, BSDH, RDH, CRCST, has over 25 years of experience in dentistry and received her BS in dental hygiene from the Massachusetts College of Pharmacy and Health Sciences. She is employed by the Midmark Corporation as a clinical educator and is an adjunct clinical instructor at Bristol Community College. She is an infection prevention consultant and owner of Compass Dental Safety. She is also a member of OSAP, most recently serving on this year’s annual conference planning committee.
Karen K. Daw, MBA, CECM, received her bachelor’s degree from Ohio State University and has a master’s in business and health-care administration. Her career includes positions as the assistant director of sterilization monitoring and clinic health and safety director for the Ohio State University College of Dentistry. She also served on OSU’s Health and Safety committee. She is a speaker, consultant, and authorized OSHA trainer, partnering with medical, dental, and hospitals across the country. Karen is a proud member of OSAP and has served as cochair for its annual conferences and bootcamps.