The ADA infection control guidelines applying to dental surgeries (incorporating Australian Standards, AS/NZS 4815:2006 and AS/NZS 4187:2014) have been updated in the latest ADA Guidelines for Infection Control – Third Edition published in October 2015.
Registered dental practitioners are legally required to be familiar with and comply with every new element of infection control practice included in the current guide and to incorporate them into their practice’s infection control manual. Policies must be documented, all clinical staff must be properly trained in infection control procedures and be made aware of the risks and obligations to themselves and patients of working in a clinical environment – which includes adhering to the mandated infection control protocols.
One of the major areas of focus in infection control is reprocessing of reusable medical devices (RMD’s) by a verified process of internal and external cleaning of the instruments; and effective sterilisation using a steam sterilizer with an appropriate cycle type (S or B type) for the load, together with the obligation to record Batch Control Identification for instruments used in critical procedures.
This aspect has received heightened attention following numerous investigations in NSW dental practices across 2015 which found failure to implement proper infection control practices and led to actions by the NSW Dental Council and the Dental Board of Australia. There were also significant infection control incidents recorded in 2015 in other Australian jurisdictions which resulted in actions against dental practitioners.
Handpiece Management
According to the ADA guidelines, all dental handpieces must be cleaned and lubricated in accordance with the manufacturer’s instructions and must be sterilized after each patient. Similarly, ultrasonic scaler handpiece inserts must be sterilized between patients. Where the entire ultrasonic scaler can be steam sterilized, then this is what should be done in line with the manufacturer’s instructions. Neither dental handpieces nor ultrasonic scaler handpieces can be fully immersed in water at any stage of cleaning.
The exterior surfaces of dental handpieces must be cleaned thoroughly and then their internal aspects cleaned and lubricated prior to sterilizing, according to the manufacturer’s instructions (e.g. using an automated lubricating and cleaning device or, less preferably, by using a hand aerosol/pressure pack spray can).
Figure 1. The W&H Assistina 3×3 makes handpiece maintenance simple and cost-effective.
“Registered dental practitioners are legally required to be familiar with and comply with every new element of infection control practice included in the current guide and to incorporate them into their practice’s infection control manual…”
Figure 2. Sterilisers must be commissioned and validated on installation and the validated on an annual basis. There is also a requirement for calibration of the thermocouples in the sterilizer by a qualified equipment technician.
Care should be taken to ensure that handpiece lubricants used do not compromise the sterilization process. It is strongly recommended automatic lubrication and flush-through systems be used for cleaning and lubricating dental handpieces because of their lower oil dosing rates. Following sterilization, handpieces must be stored in a way to prevent contamination. Handpieces should not be fitted to the dental unit until required for use on a patient. Once fitted to the dental unit and exposed to contamination during treatment, they must be reprocessed even if not used on that particular patient.
Figure 3. Instrument packs should be labelled with the steriliser identification number; date of sterilisation; and cycle or load number. Barcoding allows the instruments to be easily tracked to the individual patient treated.
A range of systems exist for lubrication of handpieces which provide effective application and removal of lubricants to the internal aspects of dental handpieces. The most recent of these has been developed by leading dental equipment manufacturer, W&H and provides a comprehensive solution for internal and external cleaning and optimum lubrication of dental handpieces. According to W&H,
the recently released W&H Assistina “3×3” automated handpiece maintenance unit is currently the only product in the world that offers an independently verified process of internal and external cleaning of handpieces, combined with optimum lubrication of the instruments. This makes it the ideal solution for effective handpiece maintenance, consistent with the latest ADA Infection Control Guidelines.
Monitoring of sterilizer cycles
An important component of the ADA Infection Control Guidelines is effective Batch Control Identification (BCI).
BCI is clearly designated as a mandatory requirement in AS/NZS 4815 and AS/NZS 4187 applying to both small dental practices and large dental health providers respectively. Both standards require pouches or packages with instruments or instrument sets used in critical procedures to have BCI recording:
a. Steriliser identification number or code (if there is more than one steriliser within the office-based health care facility);
b. Date of sterilisation; and
c. Cycle or load number.
In practice, Batch Control Identification (BCI) links a pack of surgical instruments used on a patient to a particular sterilising cycle, allowing dental practitioners to demonstrate that any critical dental instruments used on each patient have been through a particular steriliser cycle with verifiable performance data.
Dental practices are required to use a BCI system for critical individual items and instrument sets, such as those used in surgical procedures.
The 2015 ADA Infection Control Guidelines also state that it cannot be assumed sterilisation has been achieved without appropriate testing and load checking. For steam sterilization, the holding time and temperature and, where applicable, pressure, must be measured with continuous, automatic, permanent monitoring (e.g. process recorder, printer or data logger).
Figure 4. The W&H LisaSafe printer produces barcoded labels for subsequent scanning at point-of-use to correlate instrument/patient usage. W&H Lisa sterilisers include integrated data logging and W&H’s LisaWARE software maintains a permanent digital record.
Retention of hard copy printouts from steam sterilisers
According to the ADA guidelines, practices must retain printouts from steam sterilisers for a minimum of seven years. Thermal printouts tend to fade with time and become illegible, thus effective solutions are to either photocopy them to give a stable hard copy, or scan them for digital storage. Ink printouts do not fade. Some modern steam sterilisers offer data capture, wwhich is a suitable alternative provided the data is periodically downloaded from memory cards and regularly backed up.
A good example of this is the latest W&H Lisa Automatic sterilizer, which features a built-in data logger that records the details of every cycle. This data can be downloaded onto a flash memory card or automatically downloaded to computer using W&H’s LisaWARE software to maintain a permanent digital record of all batch information.
Another practical solution used in many practices is the use of a LisaSAFE bar code label printer to label instrument pouches. The barcode can then be scanned
at the chairside point of use and this information is then saved on the patient record, linking the procedure and patient with a successful sterilization cycle.
The Lisa Automatic sterilizer has the added feature of a pass code-protected load release function which means that only trained operators can release the load after verifying that the cycle has been completed satisfactorily (physical parameters met, load is dry, chemical indicators show a pass).
A requirement on all practices is the commissioning and validation of their sterilizers on installation and validation of cycle parameters on an annual basis.
There is also a requirement for calibration of the thermocouples in the sterilizer by a qualified equipment technician.
W&H has also produced a handy equipment guide entitled Sterilization, Hygiene and Maintenance, which is available from Alldent to help you choose appropriate products to support the latest infection control standards.
Regular performance testing of sterilisers must also be carried out. More details are contained in the ADA Guidelines for Infection Control – Third Edition, which is required to be kept at each dental practice for reference and can also be viewed online.
For more information see the ADA Guidelines for Infection Control