Are You Sure Your Instruments Are Ready for Sterilization?

We never want to handle wet instrument packages. If you handle wet instrument packages, what happens is the microbes that are on your hands are absorbed within the packaging material and you are incorporating microbes and compromising your sterility. And your spore test would never pick up on that. Welcome to the Phil Klein Dental Podcast. The prime objective of the instrument processing pathway that we use in our office is to deliver sterile instruments for patient care. That's the main goal. This pathway is a complex, continuous, and cyclical journey that dental instruments take on a daily basis. But this journey must be safe, predictable, efficient, and compliant. Today we're going to be talking to an expert in the field of infection control, Dr. Marie Fluent. And she's going to provide tips on how to enhance the instrument processing pathway in our office with a focus on instrument washing. She'll answer some key questions like, what are some of the typical weak points in our instrument processing protocol? And how can we address those weak points? So we're really happy to have Dr. Fluent on the show with us today. Dr. Fluent, thanks for joining us. Great to be here and see you again. And I do want to say, Dr. Fluent, before we get started, to our audience that you've done some terrific programs on infection control on VivaLearning.com. And for those interested, feel free to visit VivaLearning.com and type in Fluent, F-L-U-E-N-T in the search field, and you'll see all of Dr. Fluent's podcasts and webinars on different areas of infection control that relate to our practice. All really good stuff. So to begin this one, Dr. Fluent, tell us about yourself. in respect to you starting your career as a dental assistant and then becoming a dentist? And I ask this question because it does tie into our topic today, which we'll get into in more depth shortly. But for this first question, what motivated you to do this, to go from an assistant to a dentist? And how would you describe your journey making that transition? Sounds like an interesting question, and my journey actually began very early on in life at the age of four. I remember my mom taking me to a specialized pediatric dentist downtown Detroit in a skyscraper that seemed huge and magnificent. I rode up a magnificent elevator and entered this facility, and I just remember it being pristine and clean, and the people were warm. and friendly. And I looked out over the entire city and I thought, this is awesome. I can see doing this when I grow up one day. So fast forward out of high school, I was pursuing dentistry and I thought, hmm, I wonder if I still want to do this. So I began my career as an on-the-job trained dental assistant and learned every job within the facility. And then it confirmed my suspicions, this is where I want. So then I applied to and was lucky enough to be accepted to the University of Michigan School of Dentistry, and my career expanded from there. So you're an example of someone who started off as a dental assistant, but from the get-go, you had plans to go to dental school. Correct. I was hoping that would work out that way, and I was lucky enough that it did. And you were able to take your prerequisite requirements for dental school? As you were working as an assistant? Exactly. And I worked not only as an assistant in a general dental office, but in a periodontal office as a surgical assistant as well. And then I spent some time at the front desk as well. And I ordered supplies and instruments. And so I spent lots of time in various roles in the dental facility. And that's why I think as I'm out speaking here and now today, I can relate to different personnel because I... have sat in their seat. Right. And I'm going to ask you about that. So from the time you were an assistant, you were always very passionate about the instrument sterilization cycle and all of its nuances, because it's so important. I mean, when you think about it, in a medical environment, in a hospital, they have a whole staff for this. They have people that take care of scrubbing the floors. finishing off all the surfaces with disinfectant and taking the instruments. In a dental practice, we don't have that luxury many times, especially if it's more of a family practice or smaller practice. So we really have to know this stuff ourselves because usually the dental assistant is wearing many hats. Correct me if I'm wrong, Dr. Fluent. As an assistant, you served as an infection control coordinator for a while for the office in which you worked. And now that you're a dentist for... over 20 years, you've certainly pursued your passion as you've become arguably one of the top consultants on infection prevention in the dental setting. So do you think your experience as a dental assistant has influenced your mindset as a dentist when it comes to understanding and addressing the safest, most efficient, and predictable way to process instruments in the dental office? Absolutely. And I think my hands-on experience helped me. And if I think back at when I was trained, it was in the early to mid-1980s as HIV and AIDS was coming into being. So all of a sudden there was very much of an emphasis on instrument reprocessing, safety, infection prevention, and dentistry. And I was one of the earliest ones to learn that with regard to PPE and various precautions that were necessary. So yeah, that really sparked my passion and my interest and the importance of infection prevention in all components of dentistry. So you talk a lot about in your lectures, Dr. Fluent, the instrument processing cycle. You talk about moving from the used instruments in the operatory to transporting them to the sterilization area where they're pre-cleaned, which is optional. Then they're cleaned. They're packaged. They're sterilized, they're put into storage, and then they're ready for the next patient. Over the decades, have you seen that much of a change in this process other than the equipment that we're using, of course, is more updated and the technology and so forth? But are we doing things pretty much the same way? Or what has changed that we should be aware of as far as the instrument processing cycle? Well, of course, technology has changed quite a bit in that period of time, and we'll get into that in just a second. But the actual standard precautions and this consistency and the way that we do things has been refined for us since the HIV-AIDS epidemic and CDC composed the CDC guidelines. So now it is standardized, and every instrument should be processed the exact same way each and every time. follow these standard precautions, don't deviate from them. And we do not have to do any of the thinking ourselves or while we need to do our follow the instructions in this process that has been given to us consistently each and every time. And I want to emphasize that over and over and over again, because we'll talk about consistency and compliance. And if we do it the same way each and every time, we're not going to miss a step. That's absolutely correct. So let's talk about that briefly. When we're talking about the instrument cycle, let's talk about how safety, these are the words that you use when you lecture a lot, safety, predictability, efficiency, and compliance. Those four words are all key components in making this whole instrument cycle system work optimally. So tell us about safety, predictability, efficiency, and compliance. Talk to us about how we could do better, possibly, by employing these concepts. Okay, let's start off with the safety. aspect and I'll take you back to Arizona. I was in Arizona this year and I took a Jeep ride through the desert. And the cowboy who was giving us this ride told us to keep our arms and legs inside the Jeep at all times because everything in the desert wants to stick us, scratch us, or poke us. And it will if we're not careful and we have to watch what we're doing. And I thought, you know what? It's just like the sterilization room. Everything in there wants to stick us, scratch us, and poke us. And we need to keep our... up with each and every phase of what we're doing with regard to instrument reprocessing. We're the ones who are handling sharp contaminated instruments. There are sharp scalers, curettes, scaling instruments, even an explorer that's used for each and every procedure. If you helped it the wrong way, it's going to poke you or scratch you. So you have to think of safety first in everything that you do. So by doing that, course be careful how you handle these contaminated instruments. Handle them and manage them as little as possible. Use cassettes if they're available to you so the sharp tips are enclosed within a closed safe. carrying type of device. Of course, wear personal protective equipment so something can't splash up, get into your eyes. Wear heavy duty utility gloves if, by gosh, you are handling or hand scrubbing instruments. And I hope you're not doing that much these days anyway. And just do everything you can to keep yourself safe. for the entire process of transportation instrument cleaning inspection packaging loading the sterilizer until those instruments are finally sterile and you are safe so when you look at the instrument cycle let's go into instrument washing because that's a really important point instrument washing or instrument cleaning right because you know as an expert and you've taught this many times That if the instrument is not clean and then it's packaged for sterilization, we're going to have some deprecation in our sterilization, right? We can't ensure that the instrument is really sterile if there's debris attached to that instrument, which means it's not really fully cleaned. In some of your previous Viva Learning webinars, you recommend that we implement some form of validation at the end of our cleaning stage prior to packaging the instruments for the sterilizer. So if you would, talk about that validation. And also share with us examples of instrument washing that is typically not safe, not efficient, that may not be predictable and certainly not compliant. Well, there are three ways of cleaning your instruments. One is hand scrubbing. That is the least safe and the least efficient as far as debris removal. Then there are ultrasonic devices, which most personnel use here in the United States. That's a little bit safer. and more efficient. And then there is the use of instrument washers or washers and disinfectors that is the most efficient and poses the least risk for dental personnel. And if you're lucky enough to have one in your facility that is awesome, most people, most dental facilities here in the United States, you utilize an ultrasonic. And what was the second part of your question there? The second part of the question related to So you're in that stage of cleaning. How do we validate that the instruments are actually clean, ready to be packaged for sterilization? And that's a great question, and I'll start off with a little vignette of a story. When I purchased my practice, I inherited the ultrasonic unit from the previous dentist owner. And I said to him, and it looked like an antiquated machine to me, and I said, is it really working? And he said, sure it is. Listen to it. It's making that buzzing, vibrating sound, the high-pitched sound. I'll spare you from me trying to imitate that, but you know what I mean. And I said, yeah, but... you tested it? He said, no. to test it listen to it it's working just fine and I went okay sure so when I had a moment alone with the ultrasonic I validated it with the in the old-fashioned method the old-fashioned method is a piece of household aluminum foil dipped into that ultrasonic take for about a minute minute to a half minute and a half and then removal of that foil and you should look for uniform crinkling throughout the foil and some pitting throughout and it should be uniform throughout the entire piece of foil. And of course, when I brought that foil out, it was dead as a doornail and it went in exactly as it came, it came out exactly as it went in and that ultrasonic was completely ineffective in doing nothing to those instruments. despite the sound and the vibration and the high-pitched noise that it produced. Now we have new higher-tech methods than the old-fashioned foil technique, and these are validation strips. Some companies manufacture these with either dots or squares of ink, and they are fabricated either for the ultrasonic or the instrument washer with a holding device to put it in place. And you put that device and the strip into the cycle, let it run its complete... and at the end of that cycle when you remove that strip that spot of ink should be gone and if it's gone and it's cleared your device is working properly and if it's not You've got a problem and you need to do some investigative work. These are very common in medical settings and in dentistry, validation is not required, but it certainly is a good idea. If you're like the previous dentist who owned the practice that I purchased, you would have no idea if your ultrasonic is working or not based on the sounds that it produces and the vibration that you see. And the only way that can really be sure is if you do. an instrument validation cycle, and then ideally document the results of that as well. It's not required at this time in the United States, but boy, it sure is a good idea and a best practice. But if you don't have validation and you do have debris that's left on the instruments, what does that do as far as your outcome after it goes through sterilization? What are we looking at as far as risk? Well, that's an excellent question because if you have debris stuck on your dental instrument, the sterilant, which is the steam and the pressure, cannot penetrate that debris. Think of a scaling instrument or a dental instrument with crusted on a dental cement or composite or glass ionomer. That sterilant cannot penetrate that hard debris on that surface whatsoever. And so we cannot guarantee sterility of that. And remember, Phil, there's no such thing as a partially sterile instrument. It would be like a... positive pregnancy test. Either pregnant or not, and the instrument is either sterile or it's not. So there is no partial or in-between phase whatsoever. The instrument absolutely must be clean so the sterilant can touch and penetrate each and every surface of those dental instruments. They've got to be cleaned. So living in the litigious world that we live in, would you make the recommendation to every dentist that even though it's not required, and I'm not sure what that means, not required to have validation at the instrument cleaning stage or instrument washing stage, wouldn't that be something that's really important to have documented in the event that somebody, God forbid, gets sick from a transmissible disease, a blood-borne pathogen? Absolutely. I think it's a best practice. It's not in the CDC guidance which would which to me means it's not required at this time. But absolutely, that's why I do consider it a best practice and a great thing to be done. But it is, though, required to do validation on the sterilization side, is it not? Absolutely. Absolutely. Validation on the sterilization side is referred to as biological monitoring. And sometimes we know that as performing a spore test. And that means the same thing. And in the United States, we are required to perform a spore test or a BI biological indicator test at least once a week on all of our cycles and all of our autoclaves. And for our Canadian colleagues who are listening, they are required to perform biological monitoring daily in most provinces in Canada. And not only that, there are documentation requirements both in the United States and Canada as well. So those biological monitoring tests, they're testing the equipment, and correct me if I'm wrong, but if you don't clean the instrument properly, those tests will still show that the autoclave is operating. properly and should effectively sterilize the instruments. But if there's debris caked onto the instrument, even though you're positively, you're getting great results back on your autoclave, you could still be harboring microorganisms that are dangerous on that instrument. Is that a correct assumption? Exactly. And that is one of the loopholes. I consider all of this infection control protocol like a block of Swiss cheese. And it follows the patient safety model of, well, the Swiss cheese model. And with each thing that we do for our infection control protocol, all of the policies and protocols that we have in place, it is representative by another layer of this Swiss cheese. But within each layer, there is a hole where Something can slide through, and our policies and our protocols are not perfect. So even though you are performing a biological monitor or a spore test on a week-to-week basis, if you have debris left on your instrument, that's a hole in your Swiss cheese, and you are perfectly correct in pointing that out. Is that the weak point in the cycle? One of them, yeah. So what are some of the other weak points in the cycle, the instrument processing cycle, that we should be aware of? Another weak spot in the entire instrument reprocessing pathway would be wet instrument packages. You need to be assured that your instruments, when they go into the autoclave, are dry. So they come out of the autoclave dry. We never want to handle wet instrument packages. If you handle wet instrument packages, what happens is the microbes that are on your hands are absorbed within the packaging material, and you are incorporating microbes and compromising your sterility. And your spore test would never pick up on that. because once again, your spore test is placed in the center of the autoclave and doesn't touch the individual packages. So you need to have instruments go into the autoclave dry, they come out of the autoclave dry, and they're only handled in a dry fashion. So that's another weak spot in the entire instrument processing pathway as well. Yeah. So historically, though, dentists are doing pretty well when it comes to the transmission of bloodborne pathogens in a dental setting, right? I mean, It's overall, considering how many dentists there are and how many dental procedures are performed and how many instruments are floating around the office, we're doing pretty well. I mean, what's your assessment on that? Absolutely. And there was a study done in 2016 by Kathy Eklund. I think it was Kathy Eklund and a couple of CDC personnel who actually studied the incidence of bloodborne pathogen transmissions in the dental setting. And it was very, very low and very rare, which is a good thing. But even one is too many. And we have the power and the ability to prevent it. So we need to do that. It's our responsibility to prevent that at all costs. Yeah. So Dr. Fluent, in an ideal world, if you had the option between having an ultrasonic bath, for cleaning or an instrument washer i assume you would phase out the ultrasonic baths and focus on the instrument washer am i correct i'd like both why would you need the why would you need both Well, there are certain things that cannot go into the instrument washer and that should not ever be placed in the instrument washer. For instance, some dental burrs should never be placed in an instrument washer. If they're placed in an instrument washer, those burrs can get loose and wreak havoc with the arms of the instrument washer. And most people are gravitating towards single-use disposable burrs. But if you are in a position where... are cleaning your manufacturer's instructions for use say that you can clean and reuse these burrs the best way to do that would be to inspect them and follow the instructions for use and that typically involves an ultrasonic type of device. So I like an ultrasonic device for like smaller instrument packages or as an adjunct to the instrument washer. So I like a combination of both and I don't consider it antiquated yet, but definitely an instrument washer is a higher tech device that is much more thorough and efficient. So let's touch on efficiency in more depth when it comes to the instrument washer. It seems to me that an instrument washer, especially in the environment we're in now with a hiring crisis, it's certainly difficult to get people to come in the office and help out these days. There's a shortage of staff that I think every dentist is aware of. So anything that could be done that saves manpower and it's automated certainly makes sense. And I think the return on investment of equipment like that would come very quickly. What's your take on that? Absolutely. Team members who are reprocessing instruments can load the instrument washer, set it, forget it, and go and be on to other tasks within the dental office, and most importantly, patient care. And you're right. Our biggest price tag as a dental practice owner are the... wages for our team members. So anything that you can do to promote efficiency is profitable in a dental setting. So an instrument washer is much more efficient in that sense. There's much less standing at the sink and looking, inspecting, washing back and forth, back and forth. It's kind of like loading a dishwasher or the washing machine at home. You load it, close it. move on to other activities and come back when it's done. Right. Now I do hear some feedback from dentists saying, why don't I just get a dishwasher? What do I need to spend X number of thousands of dollars? Now you're shaking your head. The audience can't see you. The Hydrum G4 is not a dishwasher. It's quite, yeah, tell us about that. What's the difference and why spend the money for something like that? Huge difference. It makes me cringe. It's one of my pet peeves to hear dental personnel refer to that thing as a dishwasher because it's not. A dishwasher is not FDA approved for instrument washing. It's approved for household use and only household use. An instrument washer is designed to be operating. all day every day whereas a household dishwasher is designed to be used maybe once a day if even an instrument washer is designed to validate to clean every surface of every instrument in there wherever it might be located on whatever shelf. A dishwasher can't do that. We cannot prove that those instruments would be clean. In addition, there are certain requirements for the detergents to be used, which detergents, how much detergent, the water quality, the pressure on how the instruments are sprayed, the direction they are sprayed from. a whole different FDA approval process and clearance process, and companies and manufacturers have to prove and validate that their device works in a medical or dental setting. So this is not a random willy-nilly device that somebody fabricated to just spray on certain debris off of instruments. It has to be validated and proven that it is indeed effective. by the FDA Food and Drug Administration. I think based on our conversation, Dr. Fluent, there's a fair number of arguments that can be made to invest in an instrument washer. For sure, it is efficient. It's a solution for the hiring crisis as far as optimizing manpower in your office. It's safer for your employees. It validates, like you talked about just now, the fact that the cleaning cycle. is successful so that you can move on to the next step. It probably doesn't hurt staving off the attorneys when there's a disgruntled employee or patient that wants to find a loophole in your practice as far as infection control. And also the perception in the patient's eyes as far as the level of technology that's being implemented. And I'm not saying to buy every gadget that's out there, but when you're investing in technology that keeps the patient safer, that's a big deal. And patients will pick that up, take them by the sterilization room and show them, you know, what's going on. I mean, that goes a long way. The perception of an office being up to date and modernized and clean. And I think perception goes a long way, not only just for team members, but also for patients as well. When a patient walks by that sterilization room, they want to see that it is pristine. an up-to-date, not cluttered, and a well-run organized operation that's going on in that room. So for patient perception and team member perception, that's a huge thing. One office that I consult in, I went in there and the autoclave, yes, it has been passing its spore test. It was an old, old machine that the office had been using many, many years, but it was yellowed. and the plastic coating on it was crinkled and crazed and it looked grungy to the naked eyes just walking by there you'd think is that really doing anything for my instruments and would i feel safe having instruments that came out of that machine in my mouth. So perception is a huge thing, whether it be from a patient's perspective or the dental personnel's perspective. So new equipment, of course, we wanted to work well and be reliant and validated, but also we wanted to appear clean, fresh, up to date, and state of the art. And the other thing I want to mention is that the technology has greatly improved. And not only do these devices work well, but now there is internet connectivity where they can connect to the parent company. And the parent company can help monitor your cycles in real time and can notify you if there's a cycle fault for any various reason whatsoever. And so look for internet connectivity and some of the higher tech devices as well. And I know the Hydrum G4 that I mentioned earlier has that, which is very, very important. In closing, as we wrap up this podcast, Dr. Fluent, and it's been very good, what recommendations would you have for a dentist who's either starting a new practice or expanding on an existing one when it comes to building out their sterilization room? I would say plan. plan and plan. Make sure you have good advice. Make sure you have different sets of eyes looking on your sterilization area. Make sure that you can plan in advance for the growth of the practice. Say you only want to open four operatories to begin with, but down the road you want eight or ten open. You're going to need a larger sterilization area or instrument processing room and make sure that you have room for growth, room to add more autoclaves, room for more instrument storage room to add an instrument washer a room for all of your single use disposable items that need to be loaded up on instrument trays etc you're going to need room for growth so it's important to plan in advance in addition to that you want to know what you're doing you want to have a place for every task to be performed and you have want to have adequate room to perform that task so make sure you have a specialist somebody who really knows what they're doing, how to plan that space accordingly and plan for growth in the future and look at that space and make sure you don't have bottlenecks where you will have team numbers piling up on each other and you have a streamlined flow of traffic through that room as well. Dr. Fluent, the time went by pretty quickly here. Hopefully our audience feels the same way. Thank you so much for your insight and we look forward to having you on future programs. Well, thank you. Thank you for your time and thank you for the interesting discussion. It's always fun to talk to you and you bring about some very interesting points that make us look at dentistry with fresh eyes. Thank you and have a great evening. You too.