The less aseptic memory lane

June 1, 2005
Did you practice in the “wet fingered” days of dentistry? I did. By the way, for those of you who weren’t around in the good old days, “wet fingered” means before the use of gloves became standard practice.

Did you practice in the “wet fingered” days of dentistry? I did. By the way, for those of you who weren’t around in the good old days, “wet fingered” means before the use of gloves became standard practice. When I think about infection control in the early 1970s, when I began my career as a dental assistant, I am struck by how sophisticated we have become about infection prevention in dentistry.

I also find it interesting to lecture to groups of dental professionals who began practicing after OSHA standards for infection control were implemented. Most of these people simply can’t imagine working without personal protective equipment, but many of us did and survived to tell about it. Since I’m in the mood for reminiscing, I thought it might be interesting to look back at old practices and protocols to see just how far we’ve come, and perhaps to identify some protocols that may still need updating.

Back in the day, facemasks were only worn when a team member had such a bad respiratory infection that they really should have stayed home. In many cases, the same mask was worn for the duration of the respiratory symptoms.

In most dental practices, gloves were worn only to treat patients who indicated that they had hepatitis or perhaps some other type of sexually transmitted disease, such as syphilis. We also donned gloves if a patient presented with a herpes lesion or for surgical procedures.

Instruments were typically scrubbed with bare hands. We now know that wearing utility gloves during instrument cleaning helps to prevent punctures to the hands and fingers and is required by OSHA. Both OSHA and the CDC discourage the hand scrubbing of instruments, since increased handling of contaminated instruments promotes injury. Ultrasonic instrument cleaners and instrument washers have become the norm for cleaning instruments, but some of you are probably still out there scrubbing.

My advice? Stop it! Let your ultrasonic do its job first, and then selectively scrub instruments still containing debris. Using enzymatic ultrasonic solutions and enzymatic pre-treatment foams further enhance the cleaning process.

In the old days, many dental practices only packaged surgical instruments for sterilization. The CDC guidelines now recommend that all instruments must be packaged for sterilization, if they will not be used immediately. That includes extra instruments that are stored in treatment room drawers and cabinets.

In addition to packaging instruments, the CDC recommends that a process integrator be placed in each package, to ensure that the instrument pack was exposed to optimum sterilization conditions. These integrators are inexpensive, readily available strips that are placed inside the package. When the instruments are removed from the sterilizer, the strip will indicate “pass” or “fail.” If a fail is indicated, the instruments should be repackaged and reprocessed. This step is recommended in addition to the weekly monitoring of the sterilizer(s) with a biological monitor or spore test.

In my early days as a dental assistant, we never monitored the functioning of the sterilizer. In recent years, the CDC had recommended monthly monitoring. However, according to the 2003 CDC guidelines, that recommendation has changed to “at least weekly.” Spore testing can be accomplished by utilizing an outside monitoring service, by in-office testing, or a combination of the two. Some practices prefer to test in-office and then have additional validation once a month by an outside service. If your practice or facility monitors in-house, make certain that the results are recorded.

Over the years, the most dramatic procedural change has occurred in treatment room decontamination. Dental operatory disinfection used to consist of a cursory wipe of the bracket tray, air/water syringe, handpieces, light and chair switches with a 2x2 gauze saturated with isopropyl alcohol.

What we learned is that alcohol alone is not a good cleaner, since it does not readily remove blood. We also learned that items or surfaces must be cleaned prior to the application of a surface disinfectant. We now have a wide variety of cleaner/disinfectants available for use on environmental surfaces in the treatment rooms. Handpieces must be heat sterilized. Metal air/water syringe must also be sterilized, or disposable tips can be used.

And speaking of disposables, remember cleaning and “cold sterilizing” saliva ejector tips, prophy cups and brushes? Hopefully they are now being correctly utilized as single-use items in your practice or facility. The problem is that they cannot be adequately cleaned, and therefore cannot be sterilized.

Remember the blue “cold sterilization solutions?” Those solutions were simple quaternary ammonium compounds or quats. They were great disinfectants and sterilants.

When the FDA banned them, we switched to glutaraldehyde solutions, which were more effective, but were also quite toxic to our hands. Remember using bare hands to retrieve items from the cold sterile trays? Remember how your fingertips and nails turned dark yellow? Hopefully all of you are now wearing utility gloves when retrieving items from these solutions.

Fortunately, since many plastic items are now able to withstand heat sterilization, we tend to use these solutions less and less.

It is important to note that all items that can withstand heat sterilization must be heat sterilized, according to the CDC. This includes handpiece burs. A number of years ago, several studies demonstrated that autoclaving dulled cutting surfaces. This influenced some practitioners to continue to use chemical sterilization for burs and other cutting instruments, rather than heat sterilization. The reality is that burs and instruments are dulled most by repeated use. These items must be heat sterilized or disposable burs can be used. In the case of hygiene instruments, frequent sharpening is necessary to maintain effective cutting edges.

There are some nay-sayers out there who believe that simply surviving the old ways is proof that the new ways aren’t really all that necessary and important. Some believe that government regulation has ruined the practice of dentistry. In reality, before the improvements were implemented, the incidence of hepatitis B and C used to be quite high among dental professionals. According to the CDC, the incidence of hepatitis in dental settings is now extremely low. The system works, but I believe that we need to make continual procedural improvements in our lives and dental practices, always striving for better. Practical, of course, but always better.

That’s enough of my trip down memory lane. I would love hear your “wet fingered” stories or hear about your challenges in your current work settings.

Mary Govoni, CDA, RDH, MBA, is the owner of Clinical Dynamics, a consulting company based in Michigan. She is a member of the Organization for Safety and Asepsis Procedures and is a featured speaker on the ADA Seminar Series. She also writes a column for Dental Equipment & Materials magazine. She can be contacted at [email protected].