Dr. Dalin: First, let me say, Rella, that you and CRA have always been my main sources of information on infection control. As wet-gloved dentists in the “trenches,” we always look for the newest and best information on this important and often overlooked subject. I want to thank you for being there on our behalf. Our No. 1 goal has to be to protect our patients, staffs, and ourselves. Let’s talk about self- and staff protection. Is there anything new to report about masks and gloves? What should clinicians look for when selecting masks and gloves?
Christensen: There are no new mask or glove designs to jar the mind and attention of clinicians. However, the need to select efficacious masks and gloves was painfully brought to our attention with the death of health-care workers during the recent SARS epidemic. Although wearing a mask and gloves is better than nothing at all, it is absolutely essential for clinicians to understand that different products have different designs. Some designs are simply a better “mouse trap.”
Masks should fit snugly around the periphery to avoid inhaling organisms through the border of the mask. In addition, masks should be made of a material that filters in the 98 to 99 percent range. Masks should be put on so they fit snugly without being uncomfortable. The first month or two that a true, high-filtration mask with a good peripheral fit is worn, a clinician will feel like he or she is having trouble breathing. Eventually, the body will adjust as the lung capacity increases. The theory is similar to an untrained body suddenly trying to run a mile as fast as possible. It takes a period of weeks before the body adjusts to the oxygen needed per inhalation.
Criteria for choosing gloves involves seeking those with the lowest possible defects per box of 100, good fit, and low to no powder content. The glove industry is infamous for an appalling lack of information provided to clinicians regarding their products. For example, clinicians need to know the site where a glove was manufactured, the date of manufacture, and the grade of glove assigned at the factory. Even with this information, it is difficult to be sure of glove quality because other factors - such as conditions during shipping and storage before a glove reaches the dental office, as well as storage conditions after a glove reaches the dental office - contribute to the clinical quality of a glove when it is worn. Gloves should be stored in a cool environment that is ozone-free. Amazingly, many clinicians store gloves in the cupboards of the sterilization room. The cupboards are located up high, which results in the hottest possible conditions. I prefer a handed glove because it gives the greatest comfort and agility since it is designed to accommodate the thumb. Of all the infection control products used by clinicians, I believe gloves have highest priority, followed closely by facemasks. There is overwhelming evidence in the literature - dating to the late 1800s - documenting that organism transfers that result in disease occurred many times via the hands.
There are specific techniques for putting on and taking off gloves and facemasks that allow a clinician to quickly do so without self-contamination during the process. CRA’s microbiology team developed a one-hour video entitled “Infection Control Step-by-Step” that demonstrates many infection-control techniques to help clinicians learn methods that dental, dental hygiene, and assisting schools simply do not teach. This video can be obtained through Practical Clinical Courses.
Dr. Dalin: Do you think our government will outlaw the use of latex, and limit dentists solely to the use of nonlatex materials?
Christensen: No, I do not think we can go so far as to say that latex will be outlawed. I do believe, though, there may be a slow transition to the use of other materials. Unfortunately, the other materials I know about result in a higher cost to a finished glove. For the sake of economy, I think latex will remain for some time into the future. It is important to realize that most people are not hypersensitive to latex. However, the small percentage who are hypersensitive have to be extremely careful to avoid latex because of the severe body reactions that can occur. These reactions can result in death. Today, for both clinicians and patients, it is simply good sense to exercise care with any type of skin reaction in an area contacted by latex. People who are hypersensitive to latex need to practice 100 percent avoidance. In general, this can be difficult in our culture, particularly in dentistry. However, the dental industry is replacing more and more latex items with nonlatex materials.
Dr. Dalin: At one of your CRA lectures recently, I was stunned to see the “inadequate kill” blocks in your Environmental Surface Disinfectant Handout. This might be our profession’s most misunderstood area in terms of infection control. Why are we seeing these inadequate kills in CRA’s environmental surface disinfectant data?
Christensen: CRA evaluators are clinicians. We look at products as clinicians, we use products clinically, and we have a mindset from a clinical point of view. With this in mind, it is important to understand that most clinicians spread a disinfectant expecting it to kill everything rapidly - even in the presence of saliva, blood, plaque and calculus, crevicular fluid, and other body fluids. People in the industry have a different point of view. They think there are many different levels or grades of disinfectants to serve various purposes. They don’t see the need to kill broadly and rapidly all the time. For example, they view a disinfectant for the floor as needing only a low kill, whereas a disinfectant used in the operating room of a hospital needs a rapid, broad spectrum kill. By broad spectrum, I mean that the disinfectant kills many types of microorganisms such as bacteria, viruses, parasites, and yeast organisms. By rapid, I mean within one to two minutes.
Clinicians do not understand that chemicals can be called disinfectants and fail to kill the broad spectrum. They also do not understand that a product that kills broadly and rapidly, generally, has clinical characteristics that may not be pleasant. Generally, potent disinfectants have a pungent odor, attack various metals and plastics, and can be damaging on human contact if barriers such as gloves and masks are not used. Without the basic understanding of these facts, clinicians choose the disinfectants with mild and pleasant clinical characteristics, not realizing they are sacrificing the kill they expect.
So it results in a choice that every clinician eventually must make - the use of disinfectant to achieve broad spectrum rapid kill, or the use of a disinfectant to put on a show for the patients. Today, we are most worried about viral infections. We have antibiotics to treat most bacterial infections. With viruses, we have no truly effective antivirals for treatment once symptoms are manifested. The diseases we dread most in dentistry - such as hepatitis, herpes, AIDS, SARS, and bird flu - are all viral infections. The only bacterial infection you hear much about clinically is tuberculosis. Although tuberculosis can be a serious infection, a group of drugs are available for its treatment. If used correctly, they can be effective. However, antiviral drugs are available today only for the treatment of AIDS.
Being clinicians, the CRA team has devised tests for disinfectants that are clinically relevant. We have selected, as test organisms, human pathogens. We use a resistant virus and a resistant bacteria. We test in the presence of clinically relevant amounts of human bioburden that are likely to occur in serious clinical conditions. First, we test disinfectants in the absence of bioburden. Then tests are repeated in the presence of bioburden. We do this to demonstrate to clinicians a problem disinfectants have had from their inception - few disinfectants can penetrate bioburden and kill in its presence. In a clean environment, many disinfectants can kill adequately. But when saliva, plaque, and blood are present, their efficacy can be neutralized completely. This is why the disinfectant industry has directed clinicians always to clean before disinfecting. Yet, this is the most perverse idiocy a clinician could possibly practice if they are truly concerned about the spread of infection from a patient to a clinician. Think about it. A clinician who walks into a contaminated operatory and begins to rub a liquid over surfaces and objects that are highly contaminated is actually spreading the contamination across the operatory, as well as becoming self-contaminated. Disinfection needs to take place first, and be completed before cleaning. This is the order of practice in a microbiology laboratory. Likewise, a clinical operatory should be handled no differently. The procedure of choice is first to spread a fast-acting, broad spectrum disinfectant that penetrates bioburden generously throughout the operatory. Let the disinfectant stay in place at least a minute to give it time to kill. Then moisten a 4x4 cotton-filled gauze sponge until it is dripping wet with the same rapid kill, broad spectrum disinfectant. Use this sponge to remove visible debris. In summary, spread disinfectant first, and next use the disinfectant to clean. Do not clean before disinfecting.
Dr. Dalin: Which disinfectants are efficacious, and how should they be used?
Christensen: CRA has tested more than 150 different brands of disinfectants from most developed countries of the world. We have overwhelming data to demonstrate that disinfectants containing at least 70 percent by volume ethyl alcohol are the only products that can be used efficaciously in the presence of bioburden to give a rapid, broad spectrum kill. Currently, in the U. S., Lysol Sprays and Lysol IC contain 79 percent ethyl alcohol by weight. This translates to approximately 89 percent by volume at room temperature. These are extremely potent disinfectants. Currently, there are simply no other products that have the same rapid, broad spectrum kill in the presence of bioburden. These products are packaged in aerosol cans to seal the container completely so there is no volitization of the alcohol before use. We have requested that a high-ethyl alcohol disinfectant of a similar formulation be packaged like “Colonel Sanders” wraps. We see these small, foil-lined, paper-wrapped, prewet wipes carried by clinicians in their pockets, and used liberally on environmental surfaces as well as on their hands. We have not convinced any company about the value of such a product. However, we feel this type of dispensing would be superior to the aerosol can. Unfortunately, the current generation of “wipes” are isopropyl, alcohol-based products. They are packaged in such a way that the active ingredient volatilizes quickly. The isopropyl alcohol does not kill broad spectrum. In fact, it misses a whole category of pathogenic viruses. Isopropyl and ethyl alcohol are not the same chemically or antimicrobially.
Since the inception of our work, we have advised clinicians not to spray directly from the can onto surfaces when they use Lysol Sprays or any disinfectant since the disinfectant falls in droplets and is not deposited in a contiguous wet sheet. Also, spraying directly from the container encourages aerosol formation. Rather, we have suggested that a wipe - such as a 4x4 gauze sponge - be doused until it is dripping wet, and the surface be coated using the gauze sponge. The gauze sponge is held near (within one-fourth of an inch) the aerosol can dispenser in order to be wetted. This controls the aerosol spray, and also wets the sponge rapidly.
Many people ask about other Lysol brand products that are not Lysol Sprays, which contain 79 percent ethyl alcohol by weight. Unfortunately, these products have different formulations even though they have the same name. These formulations are not close to the high-ethyl alcohol formulation in antimicrobial kill. In addition, no matter how tightly you might tighten a lid on an ethyl alcohol bottle, you will never prevent volitization once the seal has been broken.
We find it amusing to see how concerned people are about breathing ethyl alcohol when using the high-ethyl alcohol disinfectants. These people have no problem drinking ethyl alcohol. Is ethyl alcohol toxic? Absolutely. All disinfectants are toxic. If they were not, they would not kill microorganisms. But, amazingly, ethyl alcohol is considered innocuous enough for people to drink it in wine, beer, and hard liquors!
Dr. Dalin: Are you satisfied with handpiece manufacturers, and the manner that dental professionals are dealing with handpiece sterilization in 2006? Is the current state of handpiece sterilization adequate?
Christensen: Today, handpieces are not the issue they were in the early 1990s, when each operatory had only one high-speed and one low-speed handpiece. Most dentists now own many handpieces and sterilize them routinely. They also own a variety of brands and designs of handpieces. Because of this, dentists realize sterilization does affect their handpieces adversely. Some handpieces tolerate the process better than others. Reluctantly, most have come to accept that they will have constant problems. What dentists don’t know is that the problems are really planned obsolescence. CRA has worked with a few handpieces that continue to operate well beyond 800 sterilization cycles. Also, there are lubrication-free turbines. With these, the mess and time-consuming lubrication process in which the lubricant is sprayed on freshly cut preparations are eliminated. But I find most dentists today have simply thrown up their hands in despair, and are tolerating the handpiece hassle.
Dr. Dalin: I think dentists realize how useful the information is that CRA routinely provides us. With the Internet, we should be able to stay abreast of this information better than ever. Are there other sources of information about infection control that are accurate and available to clinicians?
Christensen: Unfortunately, other than CRA, I do not know of any schools or organizations that test types of infection-control products to verify their efficacy.
Dr. Dalin: Let’s talk about the economics of infection control. Should infection control be charged to the patient as a separate fee, or be included in the overall procedure fee?
Christensen: I favor a separate infection-control fee so the patient can see the costs for infection control and understand that it is in addition to the procedure. However, I believe most offices today include infection control in their overall procedure costs. I list infection control as a separate fee because it is much higher than one would guess at first glance. Any clinician can calculate approximate infection-control costs by simply gathering the products they use and totaling the cost. This should include disposable products, as well as products that are used repeatedly and not disposed of - such as protective clothing, sterilizers, and ultrasonic cleaners. Several years ago, CRA’s findings showed the fee between $10 to $15 per patient. The fee is increasing along with the ever-increasing costs of dental products.
Dr. Dalin: Rella, I want to thank you, and I am sure readers of Dental Economics® are equally grateful for the information you have provided on infection control. I think many offices often get complacent about this aspect of our daily operation. We need to continue to be strong students on this subject. Is there anything else you wish to discuss?
Christensen: There are a few points I would like to make.
✔Clinicians should decide if they are really committed to the control of infectious diseases, or just going through the motions “for show” for their patients.
✔Clinicians should realize that infection control is the most product-dependent of all dental disciplines. With infection control, good technique cannot overcome products that do not work properly. For example, if masks and gloves leak, and disinfectants do not kill properly, there will be no control of the spread of infection.
✔Clinicians should learn what we call “aseptic techniques.” This is a way of handling items so a person does not touch contaminated objects - ever. So, in order to transport contaminated objects, one might use forceps, a paper towel, or other means to avoid personal contact with a contaminated object. These techniques are taught to microbiologists. Clinicians should learn the same practices.
✔Clinicians should realize there is an enormous amount of inaccurate information provided them about infection control. Industry promotions might get away with this because microorganisms are invisible, and clinicians have no way to discover the problems clinically. I think it is an ethics problem. Often, CRA and I are criticized simply for telling the truth about infection-control products. Clinicians must decide who and what they wish to believe.
✔Recently, we have had two serious wakeup calls - SARS and the bird flu. A viral pandemic happens rapidly and, generally, is deadly if a new strain mutates up the ladder of infectivity for humans. Clinicians who do not understand infection control and have not stocked efficacious products will be caught unprepared and will face dangerous exposure. A serious virus pandemic is a possibility that always exists. Clinicians must realize and understand this.
✔I compare infection control to the use of a seat belt. Both infection-control practices and seat belts should be used at all times. People tend to become weary of their use when no accidents occur. Then, suddenly, there is an accident and the seat belt or infection-control practices will save a person’s life. The bottom line is this: You either believe in prevention, practice it, and are ready when an emergency occurs, or you decide prevention is a waste of time and assume an accident cannot happen to you. Humanity has learned that, with infectious diseases, prevention is worth the trouble. I hope clinicians will believe what I have said, will decide to tighten up their procedures, and will look more carefully at infection-control products for efficacy in the clinical environment.
Rella Christensen, RDH, PhD, is chairman of the board of directors of the CRA Foundation, an educational nonprofit foundation, formerly known as Clinical Research Associates, Inc. Christensen co-founded and directed Clinical Research Associates for more than 25 years. CRA tests dental products in lab and clinical settings to confirm efficacy and clinical usefulness.
Christensen has presented more than 1,000 dental continuing education programs in the U.S., and more than 30 international programs. She has worked on research in many areas of dentistry, and published studies in books and journals on diverse topics. In addition, she has published more than 100 abstracts, and has been the lead scientist and editor-in-chief of more than 1,800 CRA Newsletter reports.
Jeffrey B. Dalin, DDS, FACD, FAGD, FICD, practices general dentistry in St. Louis. He also is the editor of St. Louis Dentistry magazine, and spokesman and critical-issue-response-team chairman for the Greater St. Louis Dental Society. Contact him by e-mail at [email protected], by phone at (314) 567-5612, or by fax at (314) 567-9047.
