When do you want to be able to say to your patients that you take their safety seriously? From the moment they walk in the door? Or after your practice is linked to a public health incident?

In recent years, a number of dental practices have made headlines after infecting patients with serious bacterial strains. Dozens of children, ranging in age from 2 to 11 years old, who were patients of an Anaheim, Calif-based children’s dental clinic were hospitalized last year after being exposed to Mycobacterium abscessus in the clinic’s water supply. This comes a year after more than a dozen patients at a children’s dental clinic in Jonesboro, Ga, suffered serious infections as a result of the same bacteria, also found in the clinic’s waterlines. In the Georgia case, many of the children were hospitalized a minimum of 10 days and required IV antibiotics. In addition, they had to have the infected baby tooth removed, as well as two or three permanent teeth underneath, and in some cases the jawbone. Half of the children suffered 50% hearing loss because of complications related to the infections and antibiotic therapy.

According to orthodontic consultant Jackie Dorst, who works as a practice consultant specializing in issues relating to instrument sterilization, dental infection control, and safety, and who holds degrees in microbiology and dental hygiene, the cell wall of the microorganism Mycobacterium abscessus has a waxy substance in it that prevents many disinfectants from being effective—for example in dental unit waterlines. Dorst contends that the infection prevention protocols set up in these practices were not tested to validate whether the disinfecting product they were using was actually working. While the staff, in good conscience, may have been putting the disinfectant tablet in the water bottle every day, they were missing a step that would have ensured that it was actually doing the job it was supposed to do.

“You can sterilize instruments in an autoclave, but if you haven’t done a spore test in your autoclave, it may not be meeting the temperature or reading the pounds per square inch. That’s why validation is required—and that validation is doing a spore test every week,” Dorst points out.

The Centers for Disease Control and Prevention (CDC) emphasized this validation step with the publication of its updated guidelines last year—the first update to the guidelines since 2003. The 2016 guidelines sought to change the overall approach from infection control to infection prevention—the goal being to prevent infections from ever happening in the first place.

Best of Intentions

For Dorst, the publication of the 2016 guidelines, which include a number of checklists for office staff, offers practices an opportunity to update where protocols may have become lax. “We get in a hurry in our lives. Orthodontic offices with one doctor see 40 to 120 patients a day. They have a lot of things on their minds. As recommendations have changed over the years, there is difficulty keeping up,” she says. Even if practices think they are keeping up to date, that may not be the case. And it can be as little as one missed procedure that can make a safe patient visit an unsafe one.

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Staying Informed?
Staying on top of the issues related to infection prevention requires continuous education. That’s why Jackie Dorst recently teamed with Hu-Friedy to lead a free 1-hour webinar focused on ensuring that each patient visit is a safe visit. The webinar, which is currently available on demand through the company’s continuing education website, focuses on proper instrument reprocessing protocols to ensure patient safety and practice efficiency.

“Instrument reprocessing is an integrated process. I want to share with the doctor and the rest of the clinical team that there are steps that their system needs to include, and how they can implement those steps into their practice,” says Dorst, who has been one of Hu-Friedy’s thought leaders for over 20 years. Moreover, she wants doctors and staff to understand how using today’s methods and techniques for reprocessing can help them protect their investment in their instruments.

In addition to a discussion of the latest reprocessing techniques, the webinar also looks at what infection prevention standards apply to orthodontic practices; how the orthodontic team can clean, disinfect, and sterilize instruments and stay on schedule; and how orthodontic instruments can be protected during sterilization.

While the webinar is designed for orthodontists, office managers, and assistants, Dorst hopes orthodontists will take the time to view it. “They need to see the big picture and the challenging components of putting state of the art instrument sterilization into place to meet compliance and efficiency,” she says. OP [/sidebar]

Dorst tells the story of one orthodontic practice where she was doing a consult. During the course of her day-long observation, she noticed the assistants were coming in with handpieces that had been cleaned and lubricated before being put into a pouch for sterilization in the STATIM, but the bur was being left in. She asked if they had forgotten to take the bur out, but they responded, “No. That’s what we’re supposed to do.” Dorst pointed out that this went against what is normally recommended and asked why they did it. “Oh, that’s what Rhonda told us to do,” they replied. When Dorst asked if she could talk to Rhonda, she learned that Rhonda had left 6 years ago after having a baby.

Dorst then asked the staff to check the manufacturer’s instructions for use (IFUs). This was met with news that the staff had just done a major clean-out and tossed hundreds of IFUs. Dorst asked the staff to get on the internet and look up the specific IFU for this handpiece. Needless to say, Dorst was right. She then explained to the staff that leaving the bur in plugged that hole. As a result, the bur limited the steam’s ability to get inside the head of the handpiece to touch the turbine blades and achieve sterilization. What’s more, leaving the bur in exposed the handpiece’s locking mechanism, or chuck, to high heat, weakening it and reducing the handpiece’s lifespan. So while the staff thought they were doing all the steps necessary to sterilize the device and protect patients, they were inadvertently putting patients at risk.

According to Dorst, the best way to ensure a practice doesn’t fall short is to abide by the CDC’s recommendation that the practice have one person who is responsible for infection prevention. This staff member should understand sterilization and should ensure that the practice has a written protocol—not the word-of-mouth instructions of an employee that’s long gone. A written protocol maintains consistency even if staffing changes. In addition, practices need to ensure staff is trained and IFUs are kept on file.

Avoiding a Costly Oversight

Practices are constantly introducing new products and technologies into their workflow. And each of these new products and technologies requires consideration as to how it will fit within the practice’s sterilization and infection prevention protocols. Practices often rely on information other than the manufacturer’s IFUs and the most up to date CDC protocol. The problem: Even if relayed in good conscience, it’s not always correct.

What’s more, even when a practice has the correct sterilization and infection prevention information from the company, that doesn’t mean the process can’t be confusing and potentially costly. Dorst shares another story, this one about Sara, an orthodontic assistant, who called to ask Dorst’s opinion on a new intraoral scanner the practice was considering. For the orthodontist, a major advantage of this one scanner was that the sleeve that goes over the scanner tip was removable and could be autoclaved up to 10 times. Sara asked Dorst what she thought about this.

Before Dorst could offer her opinion, she asked to see the manufacturer’s IFUs, which would explain how to clean, disinfect, or sterilize the equipment. Sara sent them in and Dorst had a look. The IFUs listed two specific disinfectant brands that could be used to wipe off the external equipment. No red flags there. But then the sleeve would come off, and that’s where Dorst saw a number of red flags.

First, how would the practice keep a record of the 10 times the individual sleeve was sterilized. There was no tracking system included on the sleeve itself. And while the practice could have tried using a permanent marker to record the number of cycles, how was that going to look to that ninth patient, never mind that the practice would need a pen that could survive the steam and high temperature of an autoclave cycle. But second, and most concerning, was the specific sterilizer requirements for the sleeves. The IFUs specified that a dynamic air removal sterilizer, commonly referred to as a Class B sterilizer or pre-vacuum sterilizer, was required. Dorst went back to Sara and asked what kind of sterilizer the practice had. The answer wasn’t a dynamic air removal sterilizer. While the practice may have saved money with the multiple use sleeves, it would have spent thousands more on a new sterilizer.

Dorst serves as a consultant to a number of orthodontic supply companies and her job in that role is to help companies evaluate new products. They look at how the equipment is disinfected; what are the disinfectants that can be used safely with it; and how it is sterilized. For Dorst, the important thing is that manufacturers provide compliance methods for sterilization and disinfection that are achievable and realistic for the orthodontic team. After all, the staff wants to do the right thing.

“They want to protect patients; doctors do too,” Dorst says. “They just want to know how do we do it and how do we manage it in our schedules and our physical facility.”

And here’s where compliance meets efficiency. As Dorst puts it, a practice has to understand what the sterilization and infection prevention standards are and then identify the right equipment for achieving those standards within the practice’s workflow and physical space.

Dorst contends that staff need to think about any new equipment introduction as part of an integrated system. For example, orthodontists frequently call Dorst looking for recommendations on new sterilizers after their old one has blown up. Dorst points out that the recommendation they are looking for isn’t as simple as her saying “Buy XYZ sterilizer.” There’s more to it. She needs to know much more about the practice before she can identify the right one—everything from how many patients does the practice see in a day and what size cassette does the practice want to use, to what is the size of the sterilization space and what kind of electrical outlet is available.

And beyond getting a consultant’s advice, Dorst advises orthodontists to get input from their assistants when making a final purchasing decision. “If you’re looking at investing in new equipment or putting in new systems, educate your assistants so they can [advise] you. They have enough foresight to see what the global challenges are going to be and to ask questions like Sara did. Sara asked are these sleeves going to work for us. If she hadn’t investigated, it could have been an expensive oversight.” OP