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FAQ's Instrument Processing
Frequently Asked Questions (FAQs) on Dental Infection Control
 
Top|Instruments & Equipment|Instrument Processing

 
Frequently Asked Questions for Instrument Processing
Q Does the grade of disinfectant (i.e., "intermediate" "high-level," etc.) affect the surface or items being disinfected?
Q What exactly is a cold sterilant?
Q How often should the autoclave be cleaned?
Q Is a sterilization log required indicating the cycle, length, type of load processed?
Q Should the gloves used for staff protection during instrument processing be made of nitrile?
Q What is the shelf life of a packaged instrument after it has been sterilized? Should sterile pouches be dated?
Q What are the best techniques for instrument cleaning?
Q What are the advantages and disadvantages of "flash sterilization?"
Q Why is it important to package instruments for sterilization and storage?
Q What are the ideal conditions for instrument storage?
Q What is an effective protocol for biological monitoring and instrument sterility quality assurance?
Q Can disposable items be disinfected and reused?
Q There seem to be more dental personnel complaining about dry throats, sniffling, and headaches. Is this a result of the phenolics being sprayed after each patient?
Q When using a computerized sterilizer, do you still need to do monitoring?
Q Why change the ultrasonic solution daily?
Q What are the advantages and disadvantages to the use of a dry heat sterilizer in a dental office?
Q Is dry heat equally effective in killing microorganisms as steam autoclaves?
Q The instructions for the electrosurgery tips my practices uses say to "cold sterilize” them. What cold sterilization methods does the Food and Drug Administration (FDA) approve for use?
Q How do you handle the sterilization of instruments used on known hepatitis patients? Can you put them in the ultrasonic cleaner or separate them and handscrub them? If you use the ultrasonic cleaner, do you have to then empty it and sterilize it?
Q Can we store our sterile dental instruments under the sink?
Q

Should my dentist be heat-sterilizing all of the instruments used in my mouth?


Q Does the grade of disinfectant (i.e., "intermediate" "high-level," etc.) affect the surface or items being disinfected?
A The level of disinfection is not necessarily related to any detrimental affects a disinfectant may have on surfaces. The determining factors for damage are the chemical nature of the disinfectant, the nature of the surface, and the contact time.
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Q What exactly is a cold sterilant?
A A cold sterilant is a chemical agent that can destroy all microbial life, including highly resistant bacterial endospores when used according to the directions on the product label. At shorter contact times, the product is capable of inactivating all microorganisms and some, but not all bacterial endospores.(1) Please note that most dental instruments are heat-tolerant and, as such, should be heat-sterilized via autoclave, chemical vapor, or dry heat. If chemical germicides are required, the Food and Drug Administration (FDA) maintains a list of germicides that it has cleared for market as safe and effective high-level disinfectants/sterilants when used as directed(2).

References:
(1) Sterilization or Disinfection of Medical Devices: General Principles, Division of Healthcare Quality Promotion, Centers for Disease Conrol and Prevention, available at http://www.cdc.gov/ncidod/hip/Sterile/Sterilgp.htm
(2) Food and Drug Administration. FDA-Cleared Sterilants and High Level Disinfectants with General Claims for Processing Reusable Medical and Dental Devices. Available at http://www.fda.gov/cdrh/ode/germlab.html
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Q How often should the autoclave be cleaned?
A Autoclaves should be cleaned according to the schedule described in the autoclave's instructions or operator's manual. Often the manufacturer has specific recommendations on the agents to use for the safest and most effective cleaning. If you've lost your manual, contact the autoclave manufacturer for a replacement.
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Q Is a sterilization log required indicating the cycle, length, type of load processed?
A This is required in hospitals and other institutional settings by agencies that accredit these facilities. No national mandate requires such a log in a private practice dental office, but requirements in individual states can vary. For example, Indiana requires that sterilizer time(s) and temperature(s) be documented in the dental office infection control manual. Contact your state dental licensing agency to determine if similar requirements exist in your area(1). Because recordkeeping can play a role in risk management, it may be wise to consult your attorney for advice on maintaining such records.

References:
(1) The Dental Student Network list of state licensing agencies. Available at http://www.studentdoctor.net/dental/state_boards.html
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Q Should the gloves used for staff protection during instrument processing be made of nitrile?
A The key features to look for in utility gloves -- the gloves worn when processing instruments -- are "heavy-duty"(1) and "puncture resistant" to provide more protection to the hands than thinner, patient-care gloves can afford. Nitrile, latex, and other materials such as butyl rubber may be used to manufacture heavy-duty or puncture resistant gloves. Nitrile examination or treatment gloves, however, do not meet this requirement.

References:
(1) OSHA. 29CFR 1910.1030. Bloodborne Pathogens, Final Rule. Available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051
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Q What is the shelf life of a packaged instrument after it has been sterilized? Should sterile pouches be dated?
A Although either event- or time-related practices for storage of sterile packages may be used, it is important to understand that the package contents should remain sterile indefinitely unless some outside event, such as tearing or moisture causes the pouch to become compromised. At that time it is important to repackage and resterilize the package contents to ensure sterility of the instruments. Placing a date on a package cannot ensure sterile contents if the package was compromised during the storage period. Sterile packages should, however, be marked to indicate the date the item was processed and the sterilizer they were processed in. This will facilitate recall of items in the event monitoring detects a problem with a sterilizer.
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Q What are the best techniques for instrument cleaning?
A Ultrasonic cleaners and hot-water/detergent instrument washers (with or without a thermal disinfection feature) can effectively clean dental instruments prior to sterilization. Because they minimize handling of sharp instruments, they also may reduce the risk of percutaneous injury to dental staff. Handscrubbing instruments increases the risk of contaminated sharps injuries and should not be performed unless stubborn debris remains on an item after it has been through an automated cleaning cycle. If handscrubbing is necessary, always use a long-handled brush and proper personal protective equipment (PPE), including heavy-duty utility gloves, mask, protective eyewear, and a fluid-resistant gown to prevent splash and spatter from contaminating street clothes or uniforms. Using a long-handled brush allows you to keep instruments immersed during scrubbing (to minimize splash and spatter) while keeping hands above the waterline (and away from sharp instrument ends) for added safety.
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Q What are the advantages and disadvantages of "flash sterilization?"
A Flash sterilization (sterilization of unwrapped items) may be considered if an emergency occurs (for example, the practice's only available handpiece is dropped on the floor in the middle of patient treatment) and a single instrument needs to be sterilized in a hurry. Since the item is not to be wrapped for processing, the sterilized item should be used immediately (as soon as it cools off) and must be protected from re-contamination during transport to the point of use by using a previously agreed upon protocol designed for this purpose.
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Q Why is it important to package instruments for sterilization and storage?
A Packaging cleaned instruments prior to placing them in the sterilizer is a standard of care that protects instruments and maintains their sterility until they are ready for use on a patient(1). Unprotected instruments may be re-contaminated with dust and spatter or by coming into contact with any number of non-sterile surfaces during transport, storage, tray set-up, and operatory set-up.

References:
CDC/Centers for Disease Control and Prevention. Recommended infection-control practices for dentistry, 1993. MMWR Morbid Mortal Weekly Rep 1993;42(RR-8):1-14. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00021095.htm
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Q What are the ideal conditions for instrument storage?
A Cassettes keep instruments in organized sets. They keep them separated and fairly well exposed during cleaning and sterilization, and they help reduce the direct handling of instruments (and as such, the potential for injury). The use of instrument cassettes may also extend the life of instruments with delicate working ends by protecting them during the handling that occurs as instruments are cleaned, sterilized, and stored.
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Q What is an effective protocol for biological monitoring and instrument sterility quality assurance?
A The Centers for Disease Control and Prevention (CDC), the American Dental Association (ADA), and OSAP all recommend weekly spore testing for most dental offices (1,2,3). Your state may have specific requirements for spore testing. Watching gauges and checking seals on your sterilizer (physical monitoring) and the use of chemical indicators with each instrument package (chemical monitoring) to identify items that have been exposed to heat also are important components for sterility assurance.

References:
(1) CDC. Recommended infection-control practices for dentistry, 1993. MMWR Morbid Mortal Weekly Rep 1993;42(RR-8):1-14. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00021095.htm
(2) ADA Council on Scientific Affairs and ADA Council on Dental Practices. Infection Control Recommendations for the Dental Office and Dental Laboratory. J Am Dent Assoc 1996;127:672-680. Available at http://ada.org/prof/prac/issues/topics/icontrol/ic-recs/index.html
(3) OSAP. OSAP Position Paper: Instrument Processing, January, 1997. Available at http://osap.org/issues/pages/position/pp-ip.htm
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Q Can disposable items be disinfected and reused?
A If the item is intended as single use, it should be used on one patient and then discarded. If a disposable item is intended for more than one use, it must be reprocessed under the same guidelines as those used for any other critical, semicritical, or noncritical item, depending upon its characteristics and intended use. Always follow the product manufacturer's instructions with regard to reuse life and reprocessing of disposable items.
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Q There seem to be more dental personnel complaining about dry throats, sniffling, and headaches. Is this a result of the phenolics being sprayed after each patient?
A Mild upper-respiratory complaints are non-specific and difficult to apply to specific causes. Scientifically controlled studies related to exposure to any agents are needed before causative statements can be made. Such studies are difficult to conduct and interpret. If spraying chemicals into the environment is causing concern in your office, disinfectants may be applied to surfaces via saturated pads. Dispensers that produce a stream or droplets rather than a spray can also reduce staff exposure to the chemical agent. Using barriers instead of chemical germicides on surfaces between patients also should be considered.
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Q When using a computerized sterilizer, do you still need to do monitoring?
A Biological monitoring (spore-testing) is still the medico-legal standard for sterilizer quality assurance and is required by many state dental practice acts. There are a number of factors that contribute to sterilization failure that the computer simply cannot acknowledge. The most frequent cause of sterilization failure is operator error, not malfunction of the sterilizer. The use of a biological indicator helps provide assurance that all aspects of sterilization, including both the mechanical and the procedural, are being performed as intended. If the sterilizer has a recording printer, the printout should be maintained in the sterilization log, along with the results of spore-testing.
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Q Why change the ultrasonic solution daily?
A The ultrasonic solution pulls debris, foreign particles, and contaminants from instrument surfaces and suspends them in the solution. Changing the solution at least daily, as well as when it shows visible signs of contamination, prevents over degradation of the detergent in the solution.
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Q What are the advantages and disadvantages to the use of a dry heat sterilizer in a dental office?
A Dry heat sterilization requires a higher temperature (320º - 375º F) than other sterilization processes and therefore may not be suitable for all dental instruments (most notably dental handpieces, which are not manufactured to withstand that sterilization process). The following are some of the advantages and disadvantages(1). Dry heat is effective and safe for sterilization of metal instruments and mirrors; it does not dull cutting edges, and it does not cause rust or corrosion. On the down side, it requires a long cycle for sterilization (except for forced-air, rapid heat transfer sterilizers, at 375º F); has poor penetration; may discolor and char fabric; destroys heat-labile items; cannot be used to sterilize liquids; and is generally unsuitable for handpiece sterilization. Always read and follow the instructions/directions from the manufacturer of the dry heat sterilizer you are using.

References:
(1) Molinari JA, Rosen S, Runnells RR. In Cottone JA, Terezhalmy GT, Molinari JA, eds. Practical Infection Control In Dentistry, 2nd edition. Philadelphia:Williams & Wilkins, 1996
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Is dry heat equally effective in killing microorganisms as steam autoclaves?
Dry heat sterilizers have been used effectively in dental office for many years. Just as with any other sterilization method, dry heat sterilization is highly dependent upon the operator following the manufacturer's instructions for cycle time, temperature, instrument packaging, and loading technique. Because dry air is not as efficient a heat conductor as moist heat at the same temperature, a much higher temperature is required for a dry heat unit to accomplish sterilization.(1).

There have been some recommendations that dry heat be used only in situations where moist heat is not desirable due to the material, such as oils, powders, sharp instruments and glassware(2). However, the same source points out that dry heat provides excellent penetration and prevents the corrosion of metals. Since forced-air dry heat systems have very short sterilization cycles and are kind to high carbon steel instruments, they are very often used in orthodontic practices to re-process pliers and cutters.(2)

Keep in mind that the only way to assure that sterilization parameters are routinely met is to use spore tests/biological monitors. Weekly testing is recommended.(2-4)

References:
1) Molinari JA, Rosen S, Runnells RR. In Cottone JA, Terezhalmy GT, Molinari JA, eds. Practical Infection Control In Dentistry, 2nd edition. Philadelphia:Williams & Wilkins, 1996
2) Josly L. In Block SS, ed. Disinfection, Sterilization, and Preservation, 5th edition. Philadelphia: Lippincott, Williams and Wilkins. 2001
3) CDC. Recommended Infection Control Practices for Dentistry. MMWR Morbid Mortal Weekly Report 1993;42(RR-8):1-14. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00021095.htm
4) ADA Council on Scientific Affairs and ADA Council on Dental Practices. Infection Control Recommendations for the Dental Office and Dental Laboratory. J Am Dent Assoc 1996;127:672-680.
5) OSAP. Infection Control for Dentistry Guidelines, September 1997. Available at http://www.osap.affiniscape.com/resources/IC/icguide97.htm
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Q The instructions for the electrosurgery tips my practices uses say to "cold sterilize” them. What cold sterilization methods does the Food and Drug Administration (FDA) approve for use?
A "Cold sterilization” entails the use of chemicals that FDA classifies as high-level disinfectants/sterilants. Chemicals in this category are required to have FDA clearance for their claims.

Ideally, all items that enter the patient's mouth and come into contact with oral tissues should be heat sterilized. If this is not feasible because the device or instrument cannot withstand the heat sterilization process, a high-level disinfectant should be used.

The FDA maintains a list of products that have received clearance as chemical sterilants.(1) The list includes information regarding proper contact time, active ingredients and reuse or shelf life. Always read instructions carefully before using a chemical germicide.

References:
1) Food and Drug Administration. FDA-cleared sterilants and high level disinfectants with general claims for processing reusable medical and dental devices. Available at http://www.fda.gov/cdrh/ode/germlab.html
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Q How do you handle the sterilization of instruments used on known hepatitis patients? Can you put them in the ultrasonic cleaner or separate them and handscrub them? If you use the ultrasonic cleaner, do you have to then empty it and sterilize it?
A Instruments used on known hepatitis patients do not require special reprocessing procedures. The same sterilization and other infection control precautions should be used regardless of a patient's HIV, hepatitis, or other disease status.

The Centers for Disease Control and Prevention's guidelines for infection control in dentistry state: "Universal precautions were based on the concept that all blood and body fluids that might be contaminated with blood should be treated as infectious because patients with bloodborne infections can be asymptomatic or unaware they are infected … Standard precautions integrate and expand the elements of universal precautions into a standard of care designed to protect HCP and patients from pathogens that can be spread by blood or any other body fluid, excretion, or secretion . Standard precautions apply to contact with 1) blood; 2) all body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood; 3) nonintact skin; and 4) mucous membranes. Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between universal precautions and standard precautions."(1)

In other words, the same sets of instrument processing, personal protection equipment, and engineering and work practice control precautions can be expected to protect against all bloodborne disease agents.(1) As such, instruments used on a known hepatitis patient need not be segregated from other contaminated instruments, can be cleaned in an ultrasonic cleaner, and do not require special post-cycle maintenance or cleaning of ultrasonic equipment.

References:
1) CDC. Guidelines for Infection Control in Dental Health-Care Settings --- 2003. December 19, 2003 MMWR 52(RR17);1-61 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm
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Q Can we store our sterile dental instruments under the sink?
A

Sterile items should not be stored on the floor, under sinks, on windowsills, or adjacent to air vents. Conditions in these areas can compromise the sterility of the packages and instruments.*

*CDC Oral Health Resources Frequently Asked Questions. Infection Control. Sterilization-Packaging and Storage.

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Q Should my dentist be heat-sterilizing all of the instruments used in my mouth?
A

Unless it is heat-sensitive or single-use/disposable, all items that enter the mouth should be sterilized using heat (for example, via autoclave, chemical vapor, dry heat). When available, single-use disposable items are a good infection control alternative to heat sterilizing instruments between patients. As their name suggests, single-use disposable items are used for only one patient and then discarded.

A few instruments and devices in the dental office may not be able to withstand the heat sterilization process. Any heat-sensitive item used in the mouth should be sterilized by immersion in a powerful (high-level) chemical disinfectant/sterilant for the time listed on the product's label for sterilization (usually 3-10 hours).

Ideally, heat-sensitive devices/instruments should be replaced with either heat-tolerant or single-use disposable devices.

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