Infection Control Study

Sterilization Centre Overhaul Q&A with Dr. Jordan Soll

Q | What led you to make the investment/change in your sterilization centre?

A | I was aware of the changes being introduced by Public Health and the Royal College of Dental Surgeons of Ontario. I wanted to get ahead of the curve.

Q | How did you choose your supplier and equipment? What factors influenced your choices?

A | Recommendations from my Patterson representative, who I knew had a good knowledge of the changes and requirements.

Q | What level of disruption (if any) did you or your team experience in the process of making these changes?

A | There was no disruption to our daily routine at the office. We scheduled the changes to our office during non-producing hours and integrated systems into our regular office procedures.

Q | How many sterilizers do you have in the office and why?

A | Two M11 Midmark Chambers and one Hydrim for pre-cleaning. We needed to add one sterilizer to accommodate cassettes/packages and to adhere to Public Health/RCDSO guidelines.

Q | What challenges do you face when reprocessing instruments?

A | We have a very busy office. Keeping up with the volume of instruments is challenging.

Q | What is your record keeping process?

A | Records are kept on a USB, which is transferred to a computer, along with manual recording kept in a binder, and applicator that tracks cycle number and the instruments used for treatment that is recorded in patients’ charts.

Q | Who is your designated ‘Infection Control’ person in the office and what type of training was/is involved?

A | Our Level 1 Assistant, Aaron, is our dedicated Infection Control Officer who completed all online courses from Public Health and manufacturer training for the equipment in the office.

Q | What infection control regulations do you follow?

A | Public Health Department guidelines and the RCDSO (draft).

Q | Do you talk to your patients at all about your updated sterilization processes? If so, what are their reactions?

A | We discuss with our patients the level of sterilization protocols and give regular tours of our sterilization area.

Q | What tips or advice can you share for other dentists looking at making this kind of change?

A | Simple – be proactive and be sure to know the requirements and guidelines.

Review of Instrument Sterilization Protocols

Sterilization of instruments and other reusable items is a key element of infection prevention in dentistry. Although instrument sterilization is an everyday activity in dental practices, many times all of the required steps involved in instrument sterilization are not followed, which may compromise the process as well as patient safety. This article will discuss these steps, as required and recommended by Infection Prevention and Control Canada (IPAC), Health Canada and the U.S. Centers for Disease Control and Prevention (CDC). And given the recent infection control breaches reported in Ontario, other provinces and in U.S. dental facilities; a review of instrument sterilization is probably a good strategy for every dental practice.

The instrument sterilization cycle begins with cleaning. Debris such as blood or saliva must be completely removed from the instruments, since it prevents the sterilization agent (steam or unsaturated chemical vapor) from contacting the instrument surface to kill any microorganisms present. The most common methods for cleaning instruments are the use of an ultrasonic cleaner or an automated instrument washer. Hand-scrubbing of instruments is discouraged since it presents a risk of injury to dental health care workers from punctures during handling and from spatter of debris from the instruments. The use of enzymatic ultrasonic cleaning solutions greatly increases the cleaning ability of the ultrasonic unit. In addition, there are enzyme foams or gels that can be applied to instruments prior to cleaning, that make debris easier to remove. These are particularly helpful for surgical instruments, that may have blood that has been allowed to dry on the instruments, making it more difficult to remove.

Following the manufacturer’s instructions for using an ultrasonic cleaner is critical to the success of instrument cleaning, particularly running the appropriate cycle time. This is predicated on whether the instruments are loose or in cassettes. Once the cycle is complete, the instruments must be rinsed, inspected for any remaining debris, and then dried prior to packaging. Wet instruments can damage packaging materials, which can compromise sterility of the instruments on removal from the sterilizer. In addition, excess moisture on the instruments in the sterilizer can cause staining or pitting of metal instruments.

Packaging of instruments prior to sterilization is meant to protect the sterility of the instruments from the time they are removed from the sterilizer until the instruments are used. There are several types of instrument packaging materials available, including sterilization pouches and sterilization wrap, which is most commonly used for instrument cassettes. If using sterilization pouches, it is very important to make sure that the packages are sealed appropriately, using the guides on the pouch. Occasionally an instrument tip protrudes through the packaging material, in which case the instrument must be repackaged prior to placement in the sterilizer. Instrument packages must also be labeled with the date they were processed, the sterilizer used and the load number or time of the sterilization cycle, in case of an event related to the failure of the sterilizer. These packages of instrument can then be easily identified for repackaging and reprocessing.

Although sterilization pouches have built-in process indicators to demonstrate that the packs have been run through a sterilization cycle. These indicators may not, however, measure all the parameters necessary to achieve sterilization: time, temperature and pressure/steam penetration. Integrator strips that measure all three parameters are available and can be placed inside pouches and cassettes. The use of such integrators is the only way to determine whether each individual package or instrument cassette has been subject to all the conditions for sterilization, short of using a biological indicator or spore test.

Spore testing must be performed at least weekly according to Health Canada and the CDC, but these recommendations may be changing to more frequent spore testing in some provinces. If a spore test is positive the sterilizer must be taken out of service until the results of a second spore test are available. In the rare case when there are two subsequent failures on the same sterilizer, that sterilizer must be serviced/repaired before it is placed back in service. Spore testing can be accomplished using an in-office system or a third-party sterilization monitoring service, in which the biological indicators are mailed to a facility for analysis. Each dental practice or facility must keep records of the test results.

Once instruments have been cleaned and packaged they need to be loaded into the sterilizer according to the sterilizer manufacturer’s instructions. Since improper loading of the sterilizer is a common cause of sterilizer monitoring failure, this is another critical step in instrument sterilization. Common errors in loading the sterilizer include overloading with too many packs or cassettes, layering pouches on top of other pouches or placing the paper side of a pouch incorrectly which can interfere with the drying cycle. Once again, follow the sterilizer manufacturer’s instructions for loading and also for load capacity for each cycle.

And speaking of the drying cycle, instruments pouches should not be removed from the sterilizer until the cycle is completed and the packing materials or wrap is completely dry. Wet packaging material can tear easily and can also wick in contaminants. In both cases the sterility of the instruments will be compromised. Sterilized instruments must be stored in closed cabinets or in drawers, away from moisture to protect the integrity of the packaging material.

When setting up treatment rooms for patient care, it is important to keep instruments and other sterilized devices in their packages or wraps until the patient has been seated, just prior to treatment. If instrument packages are opened well in advance of seating the patients and left exposed to room air and other environmental conditions, they may not be sterile at the beginning of a procedure. In addition, patients may not feel reassured that the instruments have indeed been sterilized if they do not have the opportunity to see the instrument packages opened in front of them.

There are many variables in the instrument sterilization process. Careful scrutiny of current processes, as well as ongoing dedication to following the appropriate protocols and steps for instrument sterilization can ensure that patients have the safest dental visit, and that dental health care professionals work in the safest possible health care setting.

Oral Health welcomes this original article.

About the Author
Mary Govoni has over 40 years of experience in dentistry. She is a Certified Dental Assistant, a Registered Dental Assistant (MI) and a Registered Dental Hygienist, with experience in general and specialty practices both clinically and as an administrator. Mary is a former dental assisting educator and was a partner in a successful dental staffing service. For the past 20 years, Mary has focused on speaking and consulting with dental teams on OSHA compliance, ergonomics, chairside efficiency and team communication and development.