By Laura Hill

At the end of the day, dentists need to feel confident that their office is clean and their instruments are infection-free for their patients. Today’s sterilization technology has become more efficient than ever, enabling them to run their practices safely and smoothly. Distributor reps can help their customers discover the right mix of products and technology that best suits their practice.

Just make it short.

“Dentists want shorter process times,” says Kim Maalouf, product manager, Midmark Corp. (Versailles, Ohio). They are looking to purchase fewer instruments and process them more efficiently, she notes. This calls for gentler processing techniques, which can help extend the life of their instruments. They also are interested in sterilizers that offer greater automation and less handling time.

Any technology that makes the sterilization process faster and more efficient will enable dentists to see more patients and generate more revenue, adds David Pfeifer, marketing manager, Kerr TotalCare (Orange, Calif.). Today, sterilizers include more automated cycles, greatly limiting opportunities for human error, he says. “Record keeping is much easier, due to compatibility of sterilizer digital records and office computer systems. Larger chambers are [now available] for cassettes, and racks help ensure proper [instrument] loading.”

As equipment improves, so do liquid sterilants, which are used for soaking and pre-cleaning instruments. Now offered in tablet form, sterilants can be shipped less expensively and stored more easily. Liquid sterilants are now available with a hydrogen peroxide base for customers who don’t want to deal with disposal issues often associated with glutaraldehyde-based products.

The right sterilizer
A sterilizer can be a sizeable purchase for a dentist. As such, he wants to buy a reliable system upfront that will last for years, says Maalouf. While some smaller units are available for a list price of $2,200 to $2,400, average sized units generally list between $5,000 and $6,000. A class B pre- and post-vacuum unit can list for as much as $7,800. The life of a sterilizer varies from one practice to the next, depending on how well maintained it is and how many cycles the practice runs each day, she explains. “On average, a sterilizer lasts nine or 10 years, with moderate use.”

There are some leading questions distributor reps can ask their customers to determine their sterilization needs:

• What type of instruments do you plan to sterilize? Some specialties, such as orthodontia, use a lot of hinged instruments. Orthodontists traditionally have opted for dry heat sterilization, with the assumption that steam sterilization may rust the hinges on their tools. Today, however, more orthodontists trust that steam sterilizers will sufficiently process their instruments, Maalouf points out.
• How big is your practice? Larger practices with, say, two dentists and three hygienists, may require more – or larger – sterilizers.
• How many instruments will you need to sterilize each day? How many sterilization cycles do you plan to run daily?
• How large are your instruments? The instruments must fit in the chamber of the sterilizer.
• What type of electrical wiring exists in your office? This may dictate the model best suited to a particular practice, notes Pfeifer.
• How large an area exists in the practice to accommodate a sterilization center? This, too, may limit the type of sterilizer a dentist can purchase.

Today, many dentists and their staff depend on intuitive sterilizers, with easy-to-use, programmable controls that allow the operator to return to his duties without having to check on the process. The unit should be designed for easy draining and filling, and it should properly dry instruments and/or packaging, according to sources at Midmark.

Reps can play an important role in their customers’ decision process by educating dentists on their sterilization options. Several different solutions are available today:

• Steam, or autoclaving
• Chemical vapor
• Dry heat
• Liquid chemical immersion.

Steam autoclaves are the “workhorses” of dental sterilization, according to Pfeifer. They combine time, temperature and pressure to sterilize instruments without emitting toxic vapors, he points out. Instruments must be dry before they are loaded, and overloading the chamber can prevent optimal sterilization. Steam cycles usually run for three to 30 minutes at 250 to 270 degrees Fahrenheit.

There are three types of steam sterilizers:

• Gravity displacement
• Steam flush pressure pulse
• Class B (pre- and post-vacuum).

Gravity displacement units work as heat builds up and steam pushes air out via gravity. This process causes a valve to open and close in the chamber, allowing air pockets to form. However, it reportedly is more difficult for steam to penetrate air pockets, or “cold spots.”

In a steam flush pressure pulse system, while the system heats up, the valve to the chamber remains closed. Following the heating process, the valve opens and permits air to pulse out. The sterilizer is pre-programmed and automatically determines when and for how long air will pulse out.

Class B sterilizers incorporate the newest technology in sterilization. Vacuum conditions are created in the chamber to pull steam in, resulting in a more rapid, efficient and effective dispersal of steam, with fewer cold spots. Pre-vacuum refers to a pump on the chamber, which sucks out air before steam and pressure build up. During the post-vacuum stage, a pump sucks out the steam at the end of the cycle, before the drying process begins. The vacuum drying cycle provides added assurance that instruments will be fully dried at the end of the process.

Cassettes vs. pouches
One of the biggest considerations in selecting a sterilizer is whether the dentist plans to use a cassette to hold instruments during the process, or whether he or she will opt for a pouch or simply load instruments loosely into the sterilizer, according to Maalouf. “Cassettes require larger sterilizers,” she says. The size of the sterilizer dictates how many cassettes it can contain.

There is a growing trend toward using cassettes, primarily due to safety concerns: There is less opportunity for the handler to get stuck by an infected instrument when using cassettes. Cassettes, which typically are pre-wrapped in paper wrap, can be transferred from the sterilizer directly to the shelf for storage. In comparison, when instruments are loaded unwrapped into the sterilizer, they must be used immediately at the end of the sterilization process to comply with current infection control guidelines, says Maalouf.

Dentists do have an option of sealing instruments in pouches prior to loading them into the sterilizer. Paper-peel pouches are plastic-coated on one side and paper on the other. The seal sticker is peeled off and the pouch secured tightly. On one hand, pouches require a smaller sterilizer. But, because steam takes longer to penetrate the pouch, the processing time is longer than when using cassettes. As with cassettes, however, pouches can be transferred directly from the sterilizer to the shelf, where sterilized instruments can remain until needed.

Alternatives
Chemical vapor sterilizers require dry instruments to avoid corrosion, says Pfeifer. Dry heat sterilizers, on the other hand, are associated with less risk of instrument corrosion and can be loaded with wet instruments. These systems disinfect instruments at extremely high temperatures (320 to 400 degrees F) for prolonged periods of time (one to two hours).

Chemical immersion, or liquid sterilants, are used either for pre-cleaning instruments prior to sterilization, or for sterilizing heat-sensitive instruments that cannot be processed in a steam autoclave. Traditionally, liquid sterilants have been glutaraldehyde-based. Some dentists may be concerned about exposure to glutaraldehyde vapors, and disposing of the chemicals can be tricky, due to Environmental Protection Agency (EPA) laws. But, glutaraldehyde is a less expensive alternative to steam sterilization, and one that some dentists still prefer.

As with most systems, glutaraldehyde liquid sterilants have their pros and cons. “Chemical sterilization [cannot] be spore-tested and validated as can heat sterilization,” says Pfeifer. “However, for instruments that are heat-sensitive, the reliability of the solution can be improved if test strips are used to confirm the concentration of glutaraldehyde, and accurate records are kept of activation dates and solution discard dates. Unlike manual sterilizers, the use of glutaraldehydes is dependent on operator compliance, with recommendations such as proper soaking time, temperature, dilution of liquid or any other action that may jeopardize the sterilization process. While the process is technique-sensitive, if [it is] done correctly, cold sterilization can be very effective and practical.” [FI]

Go with the flow
Experts agree that a sterilization center should be separated from the operatories, but easily accessible for dentists and staff. The center requires a sink for hand washing, storage cabinets and drawers, sufficient lighting and electrical service. To reduce the risk of injury to the handler or the spread of germs, and to ensure efficiency, the process should follow a specific workflow, beginning with pre-washing or decontamination. Some dentists believe they must pre-soak their instruments before putting them into the ultrasonic system or automated washer. They don’t want the soils to harden prior to sterilization, nor do they want germs and bacteria to grow while infected instruments remain in the open air, as they can contaminate patients and staff. However, instruments presoaked in a chemical solution must be rinsed before loading them into the sterilizer, creating yet another opportunity for the handler to be stuck and infected. For this reason, dentists often opt to load contaminated instruments directly into the ultrasonic cleaner or automated washer. Following pre-cleaning, instruments should be packaged, processed in a sterilizer and, finally, stored for future use.

Midmark Corp. suggests the following workflow for dentists to follow when sterilizing their instruments:

Transport instruments and handpieces to the steri-center. Contaminated instruments and handpieces should be transported in a closed, rigid, leak-proof container to minimize any risk of exposure to staff, patients or the environment. The handler should always wear personal protective equipment when transporting contaminated materials.

Sort instruments and handpieces, and properly dispose of waste. Disposable instruments should be separated and not re-used. Reusable instruments should be separated based on the type of sterilization that will follow. Some instruments require cold soaking prior to sterilization, and handpieces have a separate cleaning procedure before sterilization. All excess waste should be disposed of in a biohazard waste receptacle according to EPA mandates.

Soak and pre-clean instruments. Pre-cleaning should be conducted using a hands-free mechanical process, such as an ultrasonic cleaner or an automated washer. Hand scrubbing is unsafe for the handler, who may get stuck by an instrument.

Rinse and dry instruments. After being ultrasonically cleaned, instruments should be rinsed in clean water or, in some cases, distilled water, and dried thoroughly.

Pouch or wrap instruments. Instruments should be packaged in pouches or wrapped cassettes, unless they will be used immediately afterward. Packaging should be sealed to maintain sterility, and it should be compatible with the type of sterilization used.

Sterilize and dry instruments. It is important to have access to more than one method of sterilization or multiple sterilizers in case equipment breaks, supplies run out or electricity is interrupted.

Store sterilized instruments in a clean, dry, protected area with minimal airflow. Instruments should remain packaged until required for use. If packaging is punctured or has gotten wet, the instruments should be re-sterilized prior to use. Instruments should be rotated on a “first in, first out” basis.

The right thing to do
OSHA and the Centers for Disease Control and Prevention have guidelines for sterilizing instruments, notes Pfeifer,

But it is up to each dental office to implement a system. Manufacturers usually offer test kits for the providers to determine the viability of chemical solutions, adds Lorencovitz. But, each dental office should have a protocol for ensuring that instruments are sterilized regularly and that sterilizing equipment and solutions work proficiently.

It’s not a question of what is the law, but what is best for the dental practice, its patients and its staff. Today, providers can’t afford not to take infection control seriously.

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