Infection control — how equipment plays a role

Adrian E. LaTrace offers advice on controlling pathogens in the practice

Anyone who has read Jared Diamond’s book Guns, Germs, and Steel, understands how bacterial and viral outbreaks have altered the course of human civilization. The plagues of the early ages and Spanish influenza in 1918 serve to remind us about the unpredictability of these devastating pandemics. This century’s outbreaks of the Ebola virus in western Africa occurred at random times, affecting the citizens of the various nations as well as the healthcare workers providing care to those infected.

Closer to home, last year the United States saw its worse measles outbreak in decades with 648 confirmed cases in 27 states with the trend continuing into 2015. In 2015, 24 states have reported cases of measles with California and Illinois reporting the highest numbers. In June 2015, the state of California passed legislation in response to the Disneyland-linked measles cases that requires parents to immunize their children against measles in order to attend the state public school system. California joins 32 other states that require children to be vaccinated to prevent further spread of the disease. This all comes after the United States nearly eradicated the disease in 2000.

Methicillin-resistant staphylococcus aureus (MRSA) strains of bacteria have been the subject of studies and the media since the 1960s. Much is understood about the bacteria’s infection and transmission, but it remains a ubiquitous strain of bacteria affecting both medical and public facilities. MRSA garnered much media attention when it was discovered in the locker rooms of both high school and professional football teams. When three Tampa Bay Buccaneers football players reported MRSA infections in 2013, many in the general public became more aware of its existence, in addition to those of us in the healthcare industry. Seldom deadly in healthy individuals, most MSRA exposures result in treatable skin infections but it can manifest into a “flesh-eating bacteria” with devastating consequences.

At times, it seems we are bombarded with reports of new outbreaks of pathogens ranging from those already mentioned to that of hepatitis B or C, tuberculosis, HIV, and other transmittable diseases. I am not a doomsayer living in a plastic bubble, but rather one aware of the risks presented by the various microbes that surround us. Being armed with good infection-control protocols and products designed to minimize the exposure and transmission of these organisms will go a long way in preventing unforeseen exposure to patients. You must remain diligent in maintaining proper procedures, training your staff for their own safety, as well as your patients, and equipping your offices with products incorporating the latest infection control concepts and materials.

Today’s science provides us research and tools to better understand the nature of the many microbial threats we face. Because of this understanding, organizations such as the Centers for Disease Control (CDC) and American Dental Association (ADA) publish evidence-based guidelines to aid practices in developing their infection control protocols. In addition, the FDA and OSHA weigh in on specifics related to methods for disinfecting patient-care items and protection of your staff from pathogens. Since the CDC and ADA are not regulatory bodies, they rely on federal agencies like the FDA and OSHA to put the teeth into compliance.

I believe all dentists would agree that all their critical and semi-critical instruments should be sterilized before use on a patient. This is common sense. Based on a study published in the October 2012 edition of The Journal of the American Dental Association, entitled Advancing infection control in dental care settings, most dentists (76.9%) had attended one or more CE courses on infection control with 73% of respondents having read the CDC’s 2003 Infection Control Guidelines. However, when these same practices were surveyed on the implementation of the study’s four recommendations to promote infection control measures within the practice, only 26% had implemented three or all four recommendations. Of course, the survey was skewed toward general practice (GP) offices consistent with the overall number of GP versus all other dental specialists in the United States. This is not to imply dentists are not following the overall guidelines, but rather there is variation in their compliance methods.

The CDC guidelines promote the use of a defined process flow provided by a properly designed Sterilization Center for instrument sterilization. This should include sections for the following:

1. Clearly identified storage for contaminated (dirty) instruments
2. Ultrasonic cleaning to remove particulate matter
3. Surgical milk bath for instrument lubrication
4. Air-drying station using heated-air system
5. Wrapping area
6. Heat sterilization equipment
7. Clearly identified storage for sterile (clean) instruments

These processes need to occur in the proper order and in a linear flow to prevent transgression that could result in cross-contaminated instruments. My company suggests the Sterilization Center be custom designed to include these steps and sized specifically to the dimensions of the space where the practice assigns the sterilization room.

Ever wonder where the idiom that someone was “born with a silver spoon in their mouth” originated? Sure, it’s a centuries-old description of someone born into a wealthy family, but its origin alludes to our ancestors’ understanding of the antimicrobial properties of silver. Some sources believe the idiom has roots in the fact that silver spoons were gifts to babies born to wealthy families. Babies fed with a silver spoon tended to be healthier.

Later discovered as the “oligodynamic effect” by Swiss scientist Karl Wilhelm von Nageli, many metallic ions such as silver, copper, zinc, and gold were proven to be toxic to many forms of bacteria, viruses, and fungi. The antimicrobial effects of these metals are in use today by many medical and dental product manufacturers to prevent the spread of harmful microbes and reduce infections. Recently, equipment manufacturers have begun to use paints and other surface materials impregnated with copper to help kill harmful microbes on surfaces before they have had a chance to spread. One type of these materials developed by EOS Surfaces, LLC, a solid surface manufacturer, is called EOScu®. The product is a synthetic solid surface material enhanced with copper, which will kill over 99.9% of gram positive and negative bacteria within 2 hours of exposure. This product is a durable, attractive, solid surface material available in several colors for cabinetry countertops and delivery system cart tops. Companies such as Boyd Industries offer this product as an option in their cabinetry and side cart product line.

Advances in antimicrobial compounds can be found in upholstery materials and plastics, too. For example, OMNOVA Solutions, the upholstery material manufacturer, uses an antimicrobial protective finish in its Boltaflex® product line. This vinyl upholstery product using the company’s PreFixx® coating resists the growth of many microbes, making it ideal for dental chair and seating products. Advances in material science makes these types of coatings durable and easy to clean with a variety of common disinfectant solutions. Plastic technology advances include products such as Microban®, the anti-
microbial plastics additive. Plastics infused with this product will resist microbial growth, and because it’s blended into the plastic formulation, will not wash off or wear away. Both the upholstery and plastic additive comply with the appropriate regulatory requirements for use in healthcare facilities. The use of these types of materials when specifying your equipment in combination with diligent disinfecting procedures will greatly reduce the possibility of microbial growth on your patient chairs and staff work surfaces.

Your equipment supplier can offer several tools to assist you in accomplishing the goals of your infection control program. Here are a few tips when discussing your needs with a supplier.

• Insist on equipment made by companies whose products are listed with the FDA and have passed the regulatory testing of either Intertek or Underwriters Lab, when necessary. These products conform to standards set forth by the FDA to safeguard both the patient and clinician.
• When selecting your supplier, be sure to select a company that will work with you and your staff to select or design the products and features best suited for your practice. Companies offering a one-size-fits-all solution most likely will not be able to meet the specific requirements of your infection control program.
• Ask your supplier about the use of antimicrobial materials used to construct their products and other design features that promote the ease for disinfecting or sterilization. Products that incorporate these features will reduce the level of effort required by both you and your staff to maintain an office compliant with your infection control program.

Before making your investment decision, you should conduct thorough due diligence about the infection control characteristics of the equipment, sterilization centers, or cabinetry you are considering for purchase. This is a factor frequently overlooked when evaluating dental equipment and should be weighed along with other factors such as durability, esthetics, and ergonomics. Choosing products that include antimicrobial materials and are designed properly will provide tangible benefits in your office for many years.

All orthodontists with whom I speak certainly understand the necessity to maintain a healthy environment for their patients and staff. Of course, their practice’s infection control program and protocols are very much at the center of this imperative. As discussed, maintaining an effective infection control program will prevent the possibility of the spread of pathogens and their harmful effects. Through your talents you create wonderful smiles; your infection control program will keep them smiling.