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FAQ's Chemicals

Frequently Asked Questions (FAQs) on Dental Infection Control



Top|Practice Safety|Chemicals


Frequently Asked Questions for Chemicals

Q How do we handle mercury spills?

Q Are Vitaphene/Vital Defense D inactivated by cotton products?

Q Should mixed synthetic phenols be discarded daily or weekly?

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 What classification is alcohol in terms of its ability to disinfect: high level, intermediate level, or low level? Does ethyl alcohol kill TB? If soap is added to ethyl alcohol, will it become a more effective disinfectant? Is ethyl alcohol a sufficient disinfectant for dental office surfaces such as countertops, cupboards?

Q What type of disinfectant is best for use on dental patient chairs?

Q In the Guidelines for Infection Control in Dental Settings -- 2003 page 33 -- It is recommended that teeth be heat-sterilized to allow safe handling. And for extracted teeth containing amalgam to be immersed in 10% formalin solution for 2 weeks stating that should be effective in disinfecting both the internal and external structures of the teeth. Would it be considered acceptable to immersed all extracted teeth in 10% Formalin for 2 weeks as opposed to handling extracted teeth in 2 manners? There has been discussion that sterilized teeth are compromised during the heat sterilized process. Please advise me accordingly. I am still quite new in my job and read allot but many situations come my way in which I could use extra guidance.

Q I know that JACHO is against using gluteraldehyde, what is the position of OSAP? What research could I present before an employer to recommend change?


Q What is the source of the peracetic acid/hydrogen peroxide sterilant referenced in the Appendix I in the Oral Healthcare Missions publication. It is the last material listed, but I can't find a source.

Q Where can Peracetic Acid be obtained?


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Q How do we handle mercury spills?

A Every office that uses free mercury should be equipped with a mercury spill kit. These devices are commercially available from dental supply and lab safety supply companies. Mercury should be collected using the materials provided in the spill kit and then turned in to a licensed facility for reclaiming. The risk of mercury spills can be virtually eliminated by using precapsulated amalgam and recycling mercury containing thermometers and blood pressure gauges.

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Q Are Vitaphene/Vital Defense D inactivated by cotton products?

A No. Phenolic disinfectants are not inactivated in the presence of cotton. Iodophors, however, may be inactivated by the cellulose found in some cotton and paper products.

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Q Should mixed synthetic phenols be discarded daily or weekly?

A As with all germicidal products, the manufactures label instructions, including shelf life should be observed. If the reuse or shelf life does not appear on the label, contact the manufacturer for instructions.

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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 What classification is alcohol in terms of its ability to disinfect: high level, intermediate level, or low level? Does ethyl alcohol kill TB? If soap is added to ethyl alcohol, will it become a more effective disinfectant? Is ethyl alcohol a sufficient disinfectant for dental office surfaces such as countertops, cupboards?

A Ethanol in concentrations of 70% and higher is considered an intermediate-level disinfectant and is considered broadly virucidal and tuberculocidal. The virucidal activity of isopropanol is limited primarily to lipid-containing viruses.

Ethanol is tuberculocidal. Adding ethanol to a disinfectant formula can shorten the required contact time for inactivation of benchmark organism Mycobacterium tuberculosis but may have no effect on contact time for other organisms.

Because alcohols are poor cleaners and evaporate rapidly, they may not be the best choice for use on environmental surfaces(1). Adding soap to alcohol may improve its usefulness as a cleaner but will not increase its germicidal efficacy.

References:
1) Ali Y, Dolan MJ, Fendler EJ, Larson EL. In Block SS., ed. Disinfection, Sterilization, and Preservation, 5th edition. Philadelphia: Lippincott Williams and Wilkins, 2001

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Q What type of disinfectant is best for use on dental patient chairs?

A Contact the manufacturer of the dental chair for specific recommendations. Because new chairs should still be under warranty, you should follow the manufacturer's advice and directions/instructions. It's a good idea to ask the manufacturer to send you the written instructions for your records.

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Q In the Guidelines for Infection Control in Dental Settings -- 2003 page 33 -- It is recommended that teeth be heat-sterilized to allow safe handling. And for extracted teeth containing amalgam to be immersed in 10% formalin solution for 2 weeks stating that should be effective in disinfecting both the internal and external structures of the teeth. Would it be considered acceptable to immersed all extracted teeth in 10% Formalin for 2 weeks as opposed to handling extracted teeth in 2 manners? There has been discussion that sterilized teeth are compromised during the heat sterilized process. Please advise me accordingly. I am still quite new in my job and read alot but many situations come my way in which I could use extra guidance.

A Because formalin is a hazardous chemical, the CDC Guidelines only recommend using it for teeth that contain amalgam restorations.

The authors of From Policy to Practice: OSAP's Guide to the Guidelines also state that teeth that do not contain amalgam restorations used in educational settings should be heat-sterilized. (1)

Also, the authors of From Policy to Practice: OSAP's Guide to the Guidelines suggest consulting the manufacturer-supplied Material Safety Data Sheet (MSDS) on formalin for information on hazards, precautions, and disposal. (1)

Formalin is the only liquid germicide shown to be effective in disinfecting both the interior and exterior of extracted teeth with amalgam, making them safe for use in educational settings. Liquid chemical germicides such as glutaraldehyde and diluted bleach (sodium hypochlorite) only disinfect the exteriors of extracted teeth, not the interior pulp tissue. (1)

When using the teeth in preclinical exercises, students should apply standard precautions, even though the extracted teeth have been made safe for handling. Applying standard precautions will more accurately simulate the clinical experience. (1)

The authors of Infection Control & Management of Hazardous Materials for the Dental Team also state that the easiest and most effective procedure is sterilization by heat. Steam autoclaving is the method of choice. However, published information indicates that an unsaturated chemical vapor sterilizer is effective in neutralizing pathologic waste. (2)

Resources:

1) From Policy to Practice: OSAP's Guide to the Guidelines. Copyright 2004 by OSAP.

2) Infection Control & Management of Hazardous Materials for the Dental Team, 3rd. edition. by

Miller & Palenik. Elsevier/Mosby Publishers. Copyright 2005.


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Q I know that JACHO is against using gluteraldehyde, what is the position of OSAP? What research could I present before an employer to recommend change?

A OSAP does not test, evaluation, recommend, nor endorse specific products. We can however provide you with general information.

Yes, there are dental offices that have discontinued the use of Glutaraldehyde for high-level disinfection/chemical liquid sterilization. According to the Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental Healthcare Settings using heat-sensitive semi-critical items that must be processed with liquid chemical germicides is discouraged. Heat-tolerant or disposable alternatives are available for the majority of such items. (1)

The use of "cold” chemical sterilants (e.g. gluteraldehyde) is being discontinued for several reasons (e.g. toxic chemicals, sterilization cannot be verified, states with laws requiring sterilization be verified through use of biological monitors, etc.).

OSAP would like to refer you directly to the Centers for Disease Control and Prevention's Infection Control Guidelines for Dental Healthcare Settings. The guidelines explain the rationale for discontinuing their use as liquid chemical sterilants.

Heat-sensitive critical and semi-critical instruments and devices can be sterilized by immersing them in liquid chemical germicides registered by FDA as sterilants. When using a liquid chemical germicide for sterilization, certain post-sterilization procedures are essential. Items need to be 1) rinsed with sterile water after removal to remove toxic or irritating residues; 2) handled using sterile gloves and dried with sterile towels; and 3) delivered to the point of use in an aseptic manner. If stored before use, the instrument should not be considered sterile and should be sterilized again just before use. In addition, the sterilization process with liquid chemical sterilants cannot be verified with biological indicators. (1)

Because of these limitations and because liquid chemical sterilants can require approximately 12 hours of complete immersion, they are almost never used to sterilize instruments. Rather, these chemicals are more often used for high-level disinfection. Shorter immersion times (12--90 minutes) are used to achieve high-level disinfection of semi-critical instruments or items. These powerful, sporicidal chemicals (e.g., glutaraldehyde, peracetic acid, and hydrogen peroxide) are highly toxic. Manufacturer instructions (e.g., regarding dilution, immersion time, and temperature) and safety precautions for using chemical sterilants/high-level disinfectants must be followed precisely. These chemicals should not be used for applications other than those indicated in their label instructions. Misapplications include use as an environmental surface disinfectant or instrument-holding solution. (1)

When using appropriate precautions (e.g., closed containers to limit vapor release, chemically resistant gloves and aprons, goggles, and face shields), glutaraldehyde-based products can be used without tissue irritation or adverse health effects. However, dermatologic, eye irritation, respiratory effects, and skin sensitization have been reported. Because of their lack of chemical resistance to glutaraldehydes, medical gloves are not an effective barrier. Other factors might apply (e.g., room exhaust ventilation or 10 air exchanges/hour) to ensure DHCP safety. For all of these reasons, using heat-sensitive semi-critical items that must be processed with liquid chemical germicides is discouraged; heat-tolerant or disposable alternatives are available for the majority of such items. (1)

Resource:

1) CDC Infection Control Guidelines For Dental Healthcare Settings:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

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Q What is the source of the peracetic acid/hydrogen peroxide sterilant referenced in the Appendix I in the Oral Healthcare Missions publication. It is the last material listed, but I can't find a source.

A According to the authors of OSAP's Mission Guide, the Peracetic Acid based product in powder form that is listed in the humanitarian guide is Perasafe made by Antec International ( http://www.antechh.com ). It is not FDA cleared as a sterilant nor is it available for sale in the United States. It is approved for use in Europe and has a CE mark. Evidently, the rights to market Perasafe are owned by Dupont Chemical. Antec's distributor in the United States is Biosafety USA Inc., found at http://www.biosafetyusa.com . They do not appear to be pursuing clearance to market or to sell it here. You may however, be able to purchase it in the host country for a humanitarian mission.

As far as the authors are aware, there is no Peracetic Acid powder or concentrate based high-level disinfectant/sterilant product available for sale in the US at this time.

Although Perasafe is not currently for sale in the United States, several articles in J Hosp Infection have evaluated Perasafe against Glutraldehyde and other agents as a high-level disinfectant. Check them out at Pub Med at:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi .

(Once you are directed to Pub Med type in the word: Perasafe in the search window).

General information on Perasafe is also available from the manufacturer's site located at: http://www.antechh.com/perasafegd.html

Also, commercial airlines may not permit you to transport certain hazardous chemicals/agents. Therefore, you should contact the airlines you will travel with for possible restrictions. In order to avoid transporting chemicals you may also want to consider using one of the alternative methods for sterilization listed in the Mission Guide.

There is another alternative that you may be interested in. There is a product called Steris sterilization system. Information about it is provided by Steris in the form of a brochure. The Brochure number is M1868EN. This and other information regarding the system may be viewed at:

http://www.steris.com/resources/lit/literaturesearch.cfm?app=Gas-Liquid-Chemical%20Sterilizers#

As a note: FDA clearance to market, also referred to as a 510(k) is required for all chemical sterilants and high-level disinfectants marketed in the United States. Even though they do list different formulations of peracetic acid, they are not currently available for sale in the United States. The FDA provides a list of chemical sterilants/high-level disinfectants with trade names, manufacturers, and active ingredient that may be viewed at:
http://www.fda.gov/cdrh/ode/germlab.html

One dental infection control expert offers the following suggestion, there is a 7.5% hydrogen peroxide based product, Sporox, (Refer to the FDA's list of cleared liquid sterilants.), that may be safer to handle and dispose of in areas without the resources we have here in the United States.

The United States Air Force's Dental Evaluation and Consultation Service provides the following information concerning Sporox II: Sporox II is a chemical sterilant and high-level disinfectant for heat-sensitive instruments. The product is a pre-mixed, clear, odor-free, 7.5% hydrogen peroxide solution that is tuberculocidal, virucidal, fungicidal, bactericidal, and sporicidal. The manufacturer, Sultan Chemists, claims that Sporox II oxidizes debris quickly and effectively at room temperature, and is safe for soft metal instruments containing brass or copper. At room temperature sterilization is achieved in six hours and high-level disinfection in thirty minutes. The product can be reused for up to 21 days. Test strips are available to determine when the solution needs to be changed, and the company manufactures a sterilizing/disinfecting tray to facilitate product use. Sporox II is priced at $25 per gallon (retail) and $15.00 (government) by and can be purchased by contacting Sultan Chemists at (800) 637-8582, (201) 871-1232, FAX (201) 871-0321, or www.sultanintl.com.

United States Air Force's Dental Evaluation and Consultation Service: https://decs.nhgl.med.navy.mil/DIS61/sec7.htm

An excellent concise guide to high level disinfection under field conditions can be found on the website for the Johns Hopkins Center for Reproductive Health at:

http://www.reproline.jhu.edu/english/4morerh/4ip/IP_manual/12_HLD.pdf

You may also contact the American Dental Association (ADA) and your state/local dental society. They may be able to assist you in contacting society members who do volunteer work. The ADA and dental society should also be able to provide you with contact information for dental volunteer groups, such as the flying doctors. These groups have provided volunteer services from many years and can direct you to additional resources.

The ADA has a great deal of information on their website for health volunteers oversees. To view this information go to:

http://www.ada.org/ada/international/volunteer/directory.asp

Other resources include:

Engender Health: http://www.engenderhealth.org/res/offc/safety/ip-ref/index.html

Health Volunteers Overseas: http://www.hvousa.org

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Q Where can Peracetic Acid be obtained?

A According to the authors of OSAP's Mission Guide, the Peracetic Acid based product available in powder form that is listed in the humanitarian guide is Perasafe made by Antec International ( http://www.antechh.com ). It is not FDA cleared as a sterilant nor is it available for sale in the United States. It is approved for use in Europe and has a CE mark. Evidently, the rights to market Perasafe are owned by Dupont Chemical. Antec's distributor in the United States is Biosafety USA Inc., found at http://www.biosafetyusa.com . They do not appear to be pursuing clearance to market or to sell it here. You may however, be able to purchase it in the host country for a humanitarian mission. As far as the authors are aware, there is no powder or concentrate based high-level disinfectant/sterilant product available for sale in the US at this time.

Several recent articles in J Hosp Infection have evaluated Perasafe against Glutraldehyde and other agents as a high-level disinfectant. Check them out at Pub Med at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi . Once you are directed to Pub Med type in the word: Perasafe in the search window.

General information on Perasafe is also available from the manufacturer's site located at: http://www.antechh.com/perasafegd.html

There is another alternative that you may be interested in. There is a product called Steris sterilization system. Information about it is provided by Steris in the form of a brochure. The Brochure number is M1868EN. This and other information regarding the system may be viewed at:

http://www.steris.com/resources/lit/literaturesearch.cfm?app=Gas-Liquid-Chemical%20Sterilizers#

Additionally, OSAP has prepared a 52 page resource: Guide for Safety and Infection Control For Oral Healthcare Missions. We would like to refer you directly to this resource. It is currently free of charge if downloaded from our website. We believe this resource guide will provide you with answers to your questions concerning infection control issues during your mission trip.

The resource guide is available at: http://www.osap.org/displaycommon.cfm?an=1&subarticlenbr=15

In order to avoid transporting chemicals, the Guide offers alternative methods for sterilizing that you may like to consider.

The guide does include an appendix with a comparison chart for Sterilization and High-Level Disinfection: Available Methods and Chemical Agents. In addition, a list of available chemical sterilants/high-level disinfectants with trade names, manufacturers, and active ingredient may be viewed at: http://www.fda.gov/cdrh/ode/germlab.html

As a note: FDA clearance to market, also referred to as a 510(k) is required for all chemical sterilants and high-level disinfectants marketed in the United States. And, commercial airlines may not permit you to transport certain hazardous chemicals/agents. Therefore, you should contact the airlines you will travel with for possible restrictions.

An excellent concise guide to high level disinfection under field conditions can be found on the website for the Johns Hopkins Center for Reproductive Health at:

http://www.reproline.jhu.edu/english/4morerh/4ip/IP_manual/12_HLD.pdf

You may also contact the American Dental Association (ADA) and your state/local dental society. They may be able to assist you in contacting society members who do volunteer work. The ADA and dental society should also be able to provide you with contact information for dental volunteer groups, such as the flying doctors. These groups have provided volunteer services from many years and can direct you to additional resources.

The ADA has a great deal of information on their website for health volunteers oversees. To view this information go to:

http://www.ada.org/ada/international/volunteer/directory.asp

Some liquid sterilants require an activator while other sterilants are ready to use. One dental infection control expert offers the following suggestion, there is a hydrogen peroxide based product (Sporox by Rickett Coleman. Refer to the FDA's list of cleared liquid sterilants.), that may be safer to handle and dispose of in areas without the resources we have here in the United States.

Other resources include:

Engender Health: http://www.engenderhealth.org/res/offc/safety/ip-ref/index.html

Health Volunteers Overseas: http://www.hvousa.org

This material should help answer this and many other questions.

OSAP has further resource information on infection control issues at:

1. http://www.osap.org

2. http://www.osap.org/displaycommon.cfm?an=7

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