Recently, Dove Dental learned of another dental breach at a U. S. Dental School. It was discovered that for nearly 2 years dental handpieces were merely wiped between patients instead of following the mandatory sterilization protocol set forth by the CDC, the dental school and the manufacturer’s instructions for use (IFU). Given our access to education and technology how can this continue to occur?
Starting in the late 1990’s I spent over 10 years working with accredited teaching programs at dental schools and universities as a school and government regional manager with KaVo Dental. In those years, there were many infection control inconsistencies ranging from incorrect methodology to simple carelessness. For example, teaching basic routine dental handpiece maintenance varied between programs and in some cases was not taught at all. Unfortunately much of this became engrained and passed onto the next generation of dental professionals, as last week’s breach makes clear, this issue is ongoing.
Some of the major problems in the 90’s with improper cleaning were a result of not having enough instruments on hand to ensure proper cleaning; students were typically instructed to purchase just one handpiece (dental offices traditionally contain 3 highspeed handpieces per room). Additionally, instructions (IFU) were not strictly taught or followed with some instructors relying on central sterilization instead of teaching the student to properly clean the instrument by hand.
From my experience, variations in cleaning, sterilization and performance included:
|Variations on handpiece maintenance|
|*Using incorrect lubricant or wrong nozzle to spray|
|*Autoclave/reprocess with a sheath/bag|
|*Autoclave/reprocess with no sheath/bag|
|*Lubricating with a bur|
|*Lubricating without a bur|
|*Lubricating after sterilization|
|*Purging with a bur|
|*Purging without a bur|
|*Usage of a purge/lubrication machine vs manually|
|*Disassembly during cleaning (lowspeed components)|
|*Not disassembling lowspeeds or motors during cleaning|
|*Reprocessing that never dries|
|*Too much or too little air pressure PSI|
|*Dental water line flushing or lack there of|
|*Shortage of instruments resulting in hurried processes between patients|
|*Using a hot handpiece immediately out of the autoclave and cooled under water|
Naturally, after graduation any bad habits learned persisted and many continue today. When educators conducted due diligence at a dental office we often saw that processes were all over the map, even within a single office: some purged, some lubed, some did not purge and some lubed with odd lubricant/oils not intended for dentists. Naturally, performance reflected these practices. For example, a result of not purging was water line biofilm continuously clogged most water ports and electric motors on the market. Dental offices tended to become defensive about their procedures and quick to blame the manufacturer of handpieces for poor performance rather than focusing on proper cleaning and maintenance. And while educators noted the inconsistencies around cleaning protocols and resultant risks, much went unnoticed by the industry.
An important note: handpiece repair service was and continues to be a highly profitable business with direct ties to the inconsistent and incorrect maintenance methods learned early on.
Subsequent to my experience at KaVo Dental, I worked at SciCan and continued to witness inconsistencies in the schools, distributors and hundreds of offices that I examined. At SciCan we specialized in the Statim Sterilizer, a fairly simplistic machine. But again, practices varied resulting in some of the following:
|Variations of maintenance on Statim usage|
|*level machines that drained properly|
|*machines that dried correctly|
|*pouches that were dried correctly|
|*unleveled machines that did not drain|
|*leaking seals around cassettes resulting in failed cycles|
|*instruments (handpieces) not disassembled|
|*pouches that never dried|
|*some instruments were bagged, others were not in the same cycle|
|*never using a spore test|
|*stopping cycles ½ way through hot, because they did not have enough instruments for the next patient|
|*never cleaning the cassette|
|*never changing the bacteria filter or not knowing it exists|
|*using incorrect water in the machine|
As I continued to examine the inconsistencies, I understood that the key to proper handpiece performance at the best value is heavily influenced by the processes that maintain the instruments between patients and has little to do with the specific program or dental school. More important, patient safety is at its highest level when the dental staff is properly trained. Taken together, when processes are poorly performed or understood, repair costs are high, performance is low and the patient risk of cross contamination is tremendous.
Since 2014 I’ve served as the VP of Sales at DOVE Dental Products where I focus on teaching Evacuation Valve maintenance 101. Through hundreds of office visits, trade shows and phone interviews our company listens to how offices maintain HVE and Saliva Ejector Valves. We discover the same inconsistencies that existed in the 1990s. The use and maintenance of valves varies widely, resulting in unclean instruments, poor performance and leakage and backflow; major risks to patients, a critical issue that only grows in importance with each passing year.
|Variations of maintenance on Evacuation Valves|
|* removing the evacuation valve for cleaning frequency, sometimes, rarely, never|
|*cleaning the interior of valve frequency, sometimes, rarely, never|
|* reprocessing the valve components, sometimes, rarely, never|
|*only wiping exterior surfaces only between patients|
|*wiping, flushing between patients – some do it daily, weekly, monthly or often never|
|*cleaning the solids collector daily, weekly, monthly, or never|
|*never changing o-rings (3 in a HVE) and (2 in a Saliva Ejector) – these prevent seepage or leaking|
|*not knowing the valve is removable (very common)|
|*using a barrier between patients|
|*not using a barrier|
|*inspecting vacuum line condition routinely, sometimes, never|
|*ignoring leaks and bubbles from the sides of the instrument (very common)|
|*instructing patients to close around suction straws (very common)|
|*when patients do close around straws, nothing is mentioned to prevent Backflow|
|*warning patients to not close around straws|
When we examine dental programs today we see many of the same problems with evacuation valves that we’ve seen in the past. Many students have no idea that the valves are designed to swivel and should routinely be removed and cleaned even though every instruction guide clearly states: remove, scrub, reprocess routinely. Many rely on central sterilization or a person who maintains the chairs to insure clean and sanitary instruments. As always, patient safety is critical and it is of concern that weekly we are contacted by a dental school or program to explain “backflow,” and to question its importance as related to protecting the patient.
It’s been 20 years since we first raised concerns about water line bacteria, inconsistent maintenance of instruments and the need for consistency in infection control processes. Last week a U.S dental school had a major breach because dental handpieces were merely wiped and not properly cleaned for two years. In 1993 researchers provided solid proof that saliva ejector backflow occurs in 1 in 5 patients who close their lips around straws. However, just yesterday I had a conference call to explain saliva ejector backflow to a team of RDH’s in charge of infection control at 8 locations with nearly 50 chairs, and who did not know it exists.
Dove Dental continues to promote safe and effective dental practices for the benefit of the dental industry and for the patients. We are confident that our products provide the best solution for both dentists and patients; a simple, cost effective and expedited cleaning and maintenance regime at the dental office which insures a safe and sanitary dental experience for the patient.
For more information on Dove Dental Disposable Evacuation Valves, visit dovedentalproducts.com