A simple, 30-second step
Thirty extra seconds is what it takes to make a difference between a productive, safe work environment where a clinician can breathe freely and a contaminated one
by Shirley Gutkowski
Thirty extra seconds is what it takes to make a difference between a productive, safe work environment where a clinician can breathe freely and a contaminated one, where he or she has to fight off another cold or upper respiratory infection. Thirty seconds can mean the difference between spreading and stopping infection.
In the mid-1990s, I had the extreme pleasure of hearing Dr. Connie Drisko lecture in Milwaukee on techniques for periodontal therapy. She was so full of new and inspiring information. I'm sure I incorporated much of it into my very next clinical day. One item she addressed — the pre-procedural rinse — made an enormous difference in my own personal health and the health of anyone who heeded my insistence that they use this approach.
I know you've heard these numbers:
• Aerosols remain in the air for 30 minutes after ultrasonic scaling.
• Pre-procedural rinsing knocks down over 94 percent of the pathogens in the aerosols.
• The tests that made this discovery were done with agar plates taped up all over a treatment room. After the aerosol exposure the scientists grew the plates in an incubator and discovered that when a patient rinsed before the treatment began there was 94 percent less bacteria to grow out. That translates to fewer bacteria on the counters, walls, equipment, in the air, on the operator's clothes and in the clinician's lungs.
It was a tricky transition going from bib then reclining the patient, to bib, rinse, recline. Not as tricky as eliminating polishing, but tricky just the same. I had to remember to offer it at the beginning of the appointment (just after the bib in case they dribbled a little). Listerine™ was the least expensive option at that time. This made asking my patient to rinse for the full 30 seconds difficult. The sputtering and complaining became a little joke. As they wiped a tear from their eye, I would ask, "Did you get the bonus eye rinse?" However, I incorporated it into my practice and it's such a routine now that the patients question me if I get out of my pattern and forget to give them a cup.
Every adult patient rinsed with Listerine for 30 seconds before I reclined the chair. Most hated it, some loved it. Some patients commented on how nice it was for me to have patients with fresh breath for this nasty job. I corrected them and explained it was an infection control measure. They thought I was smart. Immediately, I started to feel healthier for longer periods of time. In the past, there were times when I thought that I'd be better off in bed than at the office. Those times became fewer and fewer.
When a hygienist or staff member complained that they were sick all of the time, I insisted that they start using a pre-procedural rinse for their patients. Those that could ignore the expressions on patient's faces during the exercise also noticed that they were sick less frequently. Many hygienists had a difficult time asking patients to rinse with a product that stung. I felt that even though we may impose dozens of unpleasant-to-the-patient things during an oral health care appointment, this was one thing that made an enormous impact on me and to any patient who arrived afterward.
Some hygienists diluted the rinse with water. I wanted to also. I remembered my chemistry classes and the importance of following precise directions, and pharmacology where milligrams and milliliters were measured in tenths and a moved decimal could kill someone. Not knowing if the rinse I was using would work mixed with water, I called the company and asked one of the researchers. He told me that they hadn't tested it diluted, but a person could rinse with water after the 30 seconds without decreasing the effectiveness. I adopted that strategy. If a patient had great difficulty with the Listerine, I would offer them water and rest assured that I was working in a disinfected field. I was never comfortable putting my patients into this much discomfort before I even started cleaning their teeth, but the science was undeniable. My health was worth it. Once patients understood that it was for disinfection, not sweeter breath, they all thought it was a great idea.
Chlorhexidine also is a great pre-procedural rinse. The directions call for rinsing for 60 seconds instead of for 30. The effectiveness is for eight hours, not one. The over-the-counter rinses were good enough for me, since I was only in the mouth for about 45 minutes. Procedures that were longer needed the chlorhexidine, and I noticed that patients liked it better. They didn't get the bonus eye rinse. Once the price of CHX came down, I looked into using it regularly instead, but it's still more than the over-the-counter brand I used.
Today there are new and exciting non-prescription products that are better at reducing the planktonic bacteria that make up the dangerous aerosols. They are friendlier to soft tissue and friendlier to cosmetic restorations. (Alcohol is not safe to use on cosmetic restorations. Over time, the alcohol dissolves the matrix of the material, leaving the restoration pitted and without sheen.) The Rembrandt product Dazzling White™ mouthwash is alcohol-free, and shown to be as effective as Listerine. I call it a no-more-tears formula. Their Age Defying mouthwash is comparable to CHX. Breath Rx also is alcohol-free and very effective for pre-procedural rinsing on a par with Listerine. Using alcohol-free mouthwashes safely increases the safety of the workplace for practitioners and patients. Compliance is great by the patient and clinician.
I think it's universally known that surface disinfectants need to remain on the surface wet for 10 minutes. We also know that most things don't stay wet for 10 minutes. Some are less than five minutes. Using barriers is a great way to get around that issue — just toss the bag out and the germs go with it. But what about disinfecting the rest of the equipment? It's important to decrease the amount of bioburden in the mouth to decrease the amount of biohazard on treatment room surfaces.
When patients rinse then expectorate into the same cup, suctioning the liquid out with the saliva ejector at the very beginning of the appointment effectively decreases the bacterial load of the last patient in the hose and the filter, as well as decreases the chance of cross contamination from the saliva ejector.
There are few reasons not to insist on pre-op rinsing. As health-care providers, we can increase our environment's safety in as little as 30 little seconds.
• J Periodontol Nov. 1991 "Reduction of salivary bacteria by pre-procedural rinses with CHX 0.12%" Veksler AE, Kayrouz VA, Newman MG.
• J Clin Periodontol Feb. 1991 "The Affect of some CHX-containing mouthrinses on salivary bacterial counts" Addy M, Jenkins S, Newcombe R.
• J Calif Dent Assoc. Oct. 2002 "Reducing bacterial counts in dental unit waterlines: Distilled water vs. antimicrobial agents" Kettering JD, Munoz-Viveros CA, Stephens JA, Naylor WP, Zhang W.
Shirley Gutkowski, RDH, BSDH, has been a full time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at firstname.lastname@example.org.