Inside Dental Assisting
May/June 2013, Volume 9, Issue 3
Published by AEGIS Communications
Q&A: All About Surface Disinfectants in the Dental Office
Just the facts on what you need to know for disinfecting
The use of surface disinfectants is part of a strategy to protect both the dental team and patients from pathogens. To assist readers, Inside Dental Assisting collected information from the authorities on infection control—Occupational Safety and Health Administration (OSHA), the Centers for Disease Control and Prevention (CDC), and the Organization for Safety, Asepsis and Prevention (OSAP)—to provide a Q&A about the use of surface disinfectants.
What is surface disinfection and why is it important?
Decontamination means the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.1
Some surfaces, especially ones that are touched often, can be teeming with microbial contamination. Most transfer of pathogens from contaminated surfaces to patients occurs through the dental personnel’s hands. Although hand hygiene is key, barrier protection, cleaning, and disinfecting of environmental surfaces also serve as important safeguards against infections.2 Following proper procedures can prevent transmission of infections among patients and the dental team.
What is a housekeeping surface and a clinical contact surface?
The CDC considers environmental surfaces to be one of two types: housekeeping and clinical contact. Housekeeping surfaces would be floors, walls, and sinks. Clinical contact surfaces are anything coming in contact with contaminated instruments, devices, hands, or gloves.2,3 These surfaces, which include switches, reusable containers of dental materials, countertops, and telephone handles, can be directly contaminated from patient materials either by direct spray or spatter generated during dental procedures.2
When should disinfectants be used?
If an impervious barrier has been used, then disinfection is not needed for that surface unless the barrier becomes compromised or the surface is inadvertently touched with contaminated gloves during removal; only replacement of the barrier between patients is required. The CDC notes that if barriers are not used, surfaces should be cleaned and disinfected between patients by using an EPA-registered hospital disinfectant that contains an HIV and HBV claim on the label such as a low-level disinfectant or a tuberculocidal claim (an intermediate-level disinfectant). Use intermediate-level disinfectants when the surface is visibly contaminated with blood or other potentially infectious materials.2
Because housekeeping surfaces have the least potential for cross-contamination, they require less stringent procedures than clinical contact surfaces.4 Some recommendations conclude that either detergent and water or a disinfectant is indicated for floors in healthcare setting.
What are the differences between low-, intermediate-, and high-level disinfectants?
Microorganisms are diverse and vary in their resistance to disinfection and sterilization. The CDC describes a low-level disinfectant as a liquid chemical germicide registered with EPA as a hospital disinfectant. OSHA requires low-level hospital disinfectants also to have a label claim for potency against HIV and HBV if used for disinfecting clinical contact surfaces. An intermediate-level disinfectant is a liquid chemical germicide registered with EPA as a hospital disinfectant and with a label claim of potency as tuberculocidal. A high-level disinfectant inactivates vegetative bacteria, mycobacteria, fungi, and viruses but not necessarily high numbers of bacterial spores. The FDA further defines a high-level disinfectant as a sterilant applied for a shorter contact time.2
The way to determine if a product is intermediate level is by whether it has a claim as a tuberculocidal disinfectant on the product label.4 Disinfectants that are EPA registered as a hospital-level disinfectant but do not kill tubercle bacillus are categorized as low-level disinfectants.
What does an EPA registration mean?
The EPA, or the U.S. Environmental Protection Agency, regulates disinfectants used on environmental surfaces. The EPA requires manufacturers to test formulations by using accepted methods for microbial activity, stability, and toxicity to humans and animals.5 Manufacturers submit these data to the EPA with proposed labeling. Once registered, the following statement must appear on all products that have been registered with the EPA under Directions for Use heading on the label: “It is a violation of federal law to use this product inconsistent with its labeling.” Dental personnel must follow the safety precautions and follow the product labeling directions. Not doing so means the product is not being used correctly.5 The EPA regulates disinfectants for use on environmental surfaces, and the Food and Drug Administration regulates the manufacture of liquid chemical sterilants and high-level disinfectants.4 The CDC is not a regulatory body and does not test or evaluate products.
How does a product become an EPA hospital disinfectant?
The product must pass the Association of Official Analytical Chemists effectiveness tests against Salmonella choleraesuis, Staphylococcus aureus, and Pseudomonas aeruginosa. Manufacturers might also test against bloodborne pathogens such as HIV, HBV, hepatitis C virus, and herpes. However, these organisms are considered fragile. So the CDC says products that satisfy the Association of Official Analytical Chemists tests for hospital disinfection are likely to be effective against these organisms when the products are used according to the manufacturers’ directions.5
Which products should be used?
Every practice is different. So no one disinfectant will serve all practices the same way.3 Surface disinfectants used in dentistry should be the same as what hospitals use. Check the label of the product to ensure it protects against HBV, HCV, and HIV. OSHA requires surface disinfectants to be efficacious against HIV and HBV.1 If blood is present on the surface, an intermediate-level disinfectant labeled as tuberculocidal should be used. The CDC states that liquid chemical sterilants should not be used as an environmental surface disinfectant.2
OSAP suggests that when choosing a disinfectant, look for the following3:
• EPA registration number
• A labeling of “hospital disinfectant”
• Low risk for triggering allergies
• Compatibility with surfaces, conditions of use, and who will use it
• Cleaning as well as disinfecting properties (for easier inventory management)
• Ease of use
• Clear directions
• A reasonable contact time (10 minutes or less)
• Acceptable storage and disposal requirements
• A reasonable life and shelf life
How can the dental teams protect their and their patient’s health when using disinfectants?
OSHA suggests that teams should check the overall safety of the product to the environment and to staff members who are exposed to it every day. Stronger disinfectants are not always better and often it means it is more hazardous to the dental team.1 Many disinfectants have organic solvents such as alcohol and phenols, which vaporize quickly and can affect indoor air quality.1 Many liquid disinfectants are corrosive, which can be harmful to people and equipment.
OSAP suggests the following for safe handling3:
Read and follow the label instructions.
Read and maintain copy of Material Safety Data Sheet.
Wear appropriate personal protective equipment (PPE), usually heavy-duty gloves, facemask, and protective apparel.
How should surfaces be cleaned?
The CDC has a simple two-step direction: Clean, and then disinfect. It suggests, “Cleaning should precede all disinfection and sterilization processes; it should involve removal of debris as well as organic and inorganic contamination.”2 Cleaning should be performed manually or mechanically, using water with detergents or enzymatic products.1 Debris can interfere with a disinfectant’s effectiveness, which is why cleaning first is essential.1 Read the label to determine whether a separate product is needed. OSAP notes that alcohols are poor cleaners and evaporate rapidly, so they may not be the best choice.
Why do products need time to work?
Following the manufacturers’ instructions is important to ensure that the product works correctly.6 T he greater the number of pathogens, the more time is needed for complete destruction.4 Cleaning surfaces before disinfection will help in this process.4 However, some products are available for the dental office that work much faster—within minutes. OSAP advises that the “areas should be cleaned and then saturated with enough disinfectant to remain for the required contact time without evaporation.”6
Are the current disinfectants used effective against emerging pathogens?
The CDC has noted the growing concern from the general public and infection-control professionals regarding the following pathogens: Cryptosporidium parvum, Helicobacter pylori, Escherichia coli O157:H7, HIV, HCV, rotavirus, norovirus, severe acute respiratory syndrome coronavirus, multidrug-resistant Mycobacterium tuberculosis, and nontuberculous mycobacteria (eg, Mycobacterium chelonae).7 The CDC has stated that these pathogens have been studied and found to be susceptible to currently available chemical disinfectants and sterilants.
What kind of disinfectant should be used for dental chairs?
Call the chair’s manufacturer for recommendations. Some disinfectants can damage fabric and materials.6
How can computers be kept free of infection?
Ideally, it is best to keep computers from areas where they may become contaminated with splatter. However, impervious barriers or shields are available to protect computers, including keyboards.6
Which is recommended: disinfecting spray or wipes?
Some states could prohibit the use of disinfectant sprays.6 O SAP advises dental teams to check with their state boards of dental examiners/licensing boards to see if disinfecting sprays are prohibited. OSAP suggests for precleaning surfaces, use a low- to intermediate-level disinfectant and the “spray-wipe-spray” technique to clean and disinfect clinical contact surfaces. Spray the surface with a cleaner or cleaner/disinfectant. Then, wipe vigorously with paper towels. Then, spray the entire surface with a disinfectant. Allow it to stay on the surface for as long as the label prescribes.
If using a wipe, wipe the towelette over the surface to remove debris, then use a clean wipe to apply disinfectant to the surface. Some manufacturers may have different instructions, which should always be followed for effective disinfection. Some wipes may be effective on a limited surface area,6 and a new wipe should be used for each surface in the dental operatory.
How often can a disinfectant wipe be used?
A fresh wipe should be used for each of the cleaning and disinfecting steps. The use of one wipe on multiple surfaces may result in the cross-contamination of surfaces.4
1. U.S . Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne pathogens, needlesticks and other sharps injuries; final rule . Fed Regist. 2001;66:5317-5325.
2. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings—2003 . MMWR Recommendations and Reports. 2003;52(RR17):1-61. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Accessed April 17, 2013.
3. Organization for Safety, Asepsis and Prevention. OSAP provides clinical contact surface disinfectant resources – 2012 update. http://www.osap.org/?page=Disinf_Info. Accessed April 17, 2013.
4. Cuny E. Managing the surfaces of the dental operatory is critical to keeping patients and staff safe from infection . Inside Dental Assisting. 2011;7(5):18-21. http://www.dentalaegis.com/ida/2011/10/disinfection-of-clinical-surfaces.
5. Centers for Disease Control and Prevention. Appendix A. Regulatory framework for disinfectants and sterilants . MMWR Recommendations and Reports. 2003;52(RR17):62-64. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a2.htm
6. Organization for Safety, Asepsis and Prevention Web site. Frequently asked questions (FAQs) on dental infection control. http://www.osap.org/?page=FAQ_Instrum_Disinf1&hhSearchTerms=surface+and+disinfectants+and+dental. Accessed April 18, 2013.
7. Rutala WA, Weber DJ; for the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf. Accessed April 17, 2013.