When it comes to keeping your orthodontic practice staff and patients free from infection, investing in high quality instruments and up-to-date sterilization technology go hand in hand.

By Tonya Johnson

The sterilization process for infectious disease control and prevention in the orthodontic market has taken a huge leap into the future, says Jackie Dorst, RDH, BS, sterilization and infection control consultant for the orthodontic profession. So if your practice is still using traditional methods like a dry heat sterilizer, with unpackaged instruments, it’s time to review and update your instrument sterilization system.

“It breaks my heart when I see doctors spend $50,000 to 100,000 remodeling a sterilization room, and they make a huge mistake because they didn’t have the right information,” says Dorst.

To learn more about the latest devices available in the sterilization process, the proper measures to take, and what’s to come in the future, Orthodontic Products conducted a roundtable discussion with Dorst; Jessica Wilson, global business development manager, infection prevention and education, HuFriedyGroup; Mike Etheridge, director of marketing, Coltene; and Doug Braendle, educational director and senior marketing manager, SciCan USA (an affiliate of Coltene).

OP: To get started, what should orthodontists consider before making an investment in instruments, cassettes, or sterilization equipment for their orthodontic practice?

Jessica Wilson
Jessica Wilson

Jessica Wilson: First, it is important to identify an infection prevention and control coordinator to manage the facility’s instrument reprocessing and infection prevention protocols. For orthodontists in particular, investing in high quality instrumentation, cassettes, and sterilization equipment can help improve efficiency, and make it easier to see a higher volume of patients each day.

Jackie Dorst: It’s a top priority for the orthodontic office to maintain an adequate inventory of sharp, functional instruments. Before buying new instruments, always request the manufacturer’s instructions for use on how to clean and sterilize them. Then verify with the manufacturer in writing (not just a signed statement from the sales representative, who may not be educated on sterilization) that those instruments are guaranteed for autoclave sterilization. Also, make sure your sterilization and cleaning  systems are up-to-date, and protect your instruments by using  a cassette system.

Jackie Dorst
Jackie Dorst, RDH, BS

Cassettes will protect instruments from the rigors of reprocessing, and provide convenient ortho instrument kit for each patient’s individual care. The cassette system also ensures that orthodontic assistants have the correct instruments needed for the procedure. Implementing a cassette instrument “Remove & Replace” system ensures sharp, cutting pliers. With this system, the assistants remove a plier in need of repair and replaces it with a sharp plier before sending the cassette through cleaning and sterilization. The dull plier is placed in the repair bin with a tape label describing the needed repair. Instruments needing repair are then sterilized and sent off for repair, or if “Beyond Repair”, to recycling such as the Hu-Friedy Environdent recycling program.

OP: What type of sterilization products and services does your company provide to protect orthodontic practices and their patients?

Wilson: At Hu-Friedy, our IMS Cassettes help practitioners keep instruments organized and protected throughout the entire reprocessing cycle, from chairside to cleaning to sterilization to storage. IMS Cassettes not only provide organization and efficiency, but also protect your instruments from damage and provide added safety for staff.

Hu-Friedy IMS Cassette

In a case study with Pacific Dental Services, IMS Cassettes were introduced into two practices and eliminated sharps injuries entirely. In a busy orthodontic practice where over a hundred patients a day can be seen, a system that supports increased efficiency and safety can be a game changer.

Hu-Friedy also provides clients with resources through the GreenLight Dental Compliance Center. It was created to help practices be confident in their compliance. The digital platform provides a single source of information for all state and federal regulations and makes it easy to develop, track, and store protocols in addition to training materials, test results, infection prevention resources, and more. During the COVID-19 pandemic, the center has remained an important resource for tracking interim guidance and ensuring compliant infection prevention programs.

doug braendle
Doug Braendle

Doug Braendle: Our latest and largest SciCan product is the STATCLAVE vacuum sterilizer. Turn-around time for the process is about 40 minutes. It can hold up to 20 instrument pouches or four full size instrument cassettes on the inside. When the process is complete, the instrument packs are dry and ready to be placed into sterile storage. SciCan offers two STATIM sterilizers, a smaller one and a larger one. Those are used for an even quicker turn-around time. But these sterilizers don’t hold cassettes. They’re used for the more expensive instruments such as handpieces that practitioners want to take extra care of. We also have a number of cleaning options, which include two automated instrument washers, the Hydrim C, a smaller one, and Hydrim L, which is the size of a regular dishwasher. We also carry ultrasonic cleaners, with larger ones (e.g., BioSonic UC150 or UC300) on the Coltene side. 

If an orthodontic office is using cassettes, we may suggest SciCan’s Hydrim line. If they are using individual pouches, they can still use a Hydrim, but will often also be able to use one of the ultrasonics. If you’re sterilizing instruments and you don’t have the proper washing equipment, washing techniques, sterilization methods, or enough sterilization equipment, staff members may have to skip lunch or work late to clean and prep instruments for the afternoon or next day’s work. At SciCan (Coltene), we also have a new SPEC program to offer recommendations and help orthodontists with their instrument flow—from dirty to clean to sterile to sterile storage, so that the sterilization process is like a fine tuned assembly line .

We help them combine a package for cleaning and sterilization that will provide them with enough equipment to fit their practice size and patient flow. Because a well-equipped orthodontic office is fun to watch (and work in), like a choreographed ballet routine. The staff members know exactly what they’re doing, and they can work efficiently and quickly. Nobody’s has to skip lunch or stay late to sterilize instruments!

Mike Etheridge
Mike Etheridge

Mike Etheridge: The automated equipment features enable staff to take cassettes,  put them inside of an instrument washer, hit start, and come back in 30 minutes. The cassettes are clean, dry, and ready to be wrapped, then placed into a sterilizer. This process is time-saving and removes the manual task of sorting instruments. The SPEC program enables doctors to decide if they want to invest in the sterilization equipment to move a smaller inventory of instruments and cassettes through the process, or buy more instruments. Depending on the daily number of patients seen, and the sterilization capacity, you should be able to process instruments 1-2 times in the morning and 1-2 times in the afternoon to meet the patient load. However, if you can only move those instruments through the system one time in the morning and one time in the afternoon because of the steri-center capacity, then you’ll have to have to buy more cassettes and orthodontic instruments. 

OP: Which of the FDA approved sterilization methods do you most recommend for the cleaning of dental instruments?

Dorst: The dry heat method has become an outdated form of sterilization because of the dry heat limitation for sterile instrument packaging materials. The CDC sterilization guidelines state that all critical and semi critical instruments should be packaged before sterilization and remain packaged until used with patients. Dry heat sterilizes at a higher temperature, between 375 to over 400 degrees. Most paper, plastic, and tape sterile packing materials melt or burn at the high dry heat temperatures. High dry heat sterilization temperatures can damage the mechanisms built inside of a high-speed or slow-speed handpiece. Using the dry heat method for orthodontic pliers requires  orthodontists to have an additional steam autoclave sterilizer for the handpieces and plastic items. The steam autoclave system sterilizes items at a lower temperature, between 250 to 273 degrees. Orthodontic pliers, instruments, and cassettes can be sterilized at 270 to 273 degrees, with 18 to 21 pounds of pressure per square inch. Plastic items must be sterilized at a temperature between 250 to 253 degrees. The lower autoclave temperature is a real advantage for orthodontic practices that use devices like the plastic cheek retractors, or the Nola Bilateral suction during the bonding process.

Wilson: Steam sterilization is the main sterilization choice. It is also important to follow the instructions for use on all items to be reprocessed. Most products used today are validated using steam sterilization. 


OP: Explain the importance of validation for sterilization, and how does the process work?

Wilson: Practices must monitor the performance of their steam sterilizer(s) and the dental instrument loads being processed to ensure that critical instruments are sterile and safe for patient use (preventing healthcare acquired infections). This can be accomplished by monitoring a combination of mechanical, chemical, and biological process parameters. Mechanical techniques for monitoring sterilization include observing, confirming, and recording cycle time, temperature, and pressure for each load. Process or chemical indicators should be used with each instrument pack to detect exposure to one or more parameters of the sterilization process depending on the type, confirming that the sterilizing agent has penetrated the packaging material and actually reached the instruments inside. Finally, biological indicators (BIs) are the most stringent method for monitoring the sterilization process because they assess it directly by testing the sterilizer’s ability to kill highly resistant microorganisms (eg, Geobacillus), rather than merely testing the physical and chemical conditions. Because spores used in BIs are more resistant than the common microbial contaminants found on patient-care equipment, a passing test BI indicates potentially dangerous pathogens in the load have been effectively killed. A BI test should be used at least weekly to monitor sterilizers.

[Watch Now: Remodeling an Outdated Sterilization Room: A 4-part Video Series]

OP: What’s trending in the market? Are you excited about the industry’s future?

Dorst: I’m excited about the new dynamic air removal autoclaves. This technology can remove the steam at the end of a cycle, therefore reducing the sterilization time. It also removes moisture and the steam to speed up the drying process, so the orthodontic team doesn’t have to wait as long to prep for the next patient.

Etheridge: Surgically Clean Air designs a machine that cleans and sanitizes the air a couple of times a day in the office. We’re also seeing more suction devices being created to pull the aerosol out of the room when doctors are using handpieces or hygienists are using ultrasonic scalers.

Braendle: Some of the latest equipment also includes portable suction units/deflectors that can be placed near the oral cavity when a practitioner is working. So the device will evacuate particles inside of a patient’s mouth. In a post-COVID-19 environment, I don’t know what the investment in technology will look like. But when a problem presents itself, there are always entrepreneurs out there willing to solve it with some efficacy. OP

8 Tips for Updating Your Sterilization Room:

If you’re ready to update your practice with the latest instruments, cassettes, and/or sterilization technology, consider the following advice from our featured roundtable experts:

  1. Investing in high quality instrumentation, cassettes, and sterilization equipment can help improve efficiency, and make it easier to see a higher volume of patients each day.
  2. Make sure your sterilization and disinfection systems are up to date.
  3. It’s a top priority for the orthodontic practice to maintain a quality inventory of instruments. Identify an infection prevention and control coordinator (or hire an orthodontic sterilization consultant) to manage your facility’s instrument reprocessing and infection prevention protocols.
  4. Before purchasing new instruments, always request the manufacturer’s instructions for use on how to clean and sterilize the product.
  5. Verify with the instrument manufacturer in writing (not just a signed statement from the sales representative, who may not be educated on sterilization) that those instruments are guaranteed for current autoclave sterilization methods.
  6. If you’re using a cassette system, determine how many cassettes you use in the morning and how many you use in the afternoon. That will help determine the amount and size of sterilization equipment you’ll need to invest in. It will also prevent you from making an expensive purchasing mistake.
  7. Ensure your instruments remain sterile by using sterilization pouches or a wrapped cassette system. Cassettes will protect instruments from the rigors of reprocessing, and provide convenient setup for each patient’s individual care. The cassette system also ensures  that orthodontic assistants have the correct instruments needed for the procedure.
  8. If you have the space, showcase the sterilization process at your facility. At some practices, patients can view the sterilization center behind glass wall as they walk through the hallway. It’s a feature to be proud of because if a patient is worried about infections, they’ll be reassured, then spread the word. That’s a plus for your practice. OP

Tonya Johnson is associate editor of Orthodontic Products.