Dental clinical evaluation
Clean, disinfect and cover –
Top activities for clinical contact
surfaces in dentistry
In collaboration with Integrated Orthodontic Services srl, Lecco, IT.
December 2015
Dr. Livia Barenghi
Clean, disinfect and cover –
Top activities for clinical contact
surfaces in dentistry
Dr. Livia Barenghi
A graduate in biological sciences and a specialist in biochemistry and clinical chemistry, Ms
Barenghi’s area of interest is biotechnology and most recent scientific work has concentrated
on stem cell research and procedures for the sterilisation of the complex devices used for this
purpose. She currently works principally in the field of dentistry with a particular focus on the
reprocessing procedures for reusable medical equipment, and procedures and products for the
disinfection of high contact clinical surfaces and dental unit water lines. Her academic activities
are mainly focused on the dental profession. www.ios-srl.com
This article analyses several products and procedures for the
management of Clinical Contact Surfaces’ (CCSs) (See definition
inset Box 1) contamination levels, in a way that is appropriate to
both clinical and occupational risks in dentistry (see Table 1 and 2
and inset Box 2 on wipes). Nowadays it is widely recognised that
environmental surface contamination plays an important role in
the transmission of health care associated infections.1 Dry, clinical
contact surfaces are considered high risk as they are contaminated
by pathogens that are often drug resistant, and this favors the hand
based transmission of microbes.2-4 Approximately 20 percent of
pathogens are transmitted by contaminated surfaces and 20 to 40
percent by contaminated hands.1
Introduction
As it is reasonable to expect, inanimate clinical surfaces (both
environment and instruments) that come under frequent contact play
a role in the risk of infection, even in dentistry. Numerous pathogens
live and are able to survive on dental surfaces. Common mistakes
(such as hurried hand wash, touching of facemask, taking objects
out of drawers during dental procedures and with contaminated
hands, absentmindedly removing gloves, frequently touching
multi use vials containing bonds, cements, pastes, etc.) carry the
risk of considerable surface contamination. They can also create
environmental niches that favour the survival of microorganisms
or biofilms, for instance on numerous dental objects with non
smooth surfaces, narrow cracks or chips caused by wear and tear.
Reportedly, Staphylococcus aureus contaminates the dominant
hand and the tray used during dental procedures in 5 percent of
cases. Drug resistant bacteria contaminate in 1.5 percent of cases.5
Surface Decontamination (SD) must therefore be included in the wider
programme for the prevention of cross infection. The programme
provides operators with a greater awareness, in particular for what
concerns personal hygiene (hand washing and the use of Personal
Protective Equipment – PPE), the reduction of environmental
contamination (use of a surgical suction unit and dam; disinfection
of the dental unit water lines; exchange/purification of air; prevention
of evaporation from ultrasonic baths, etc.) and the employment of
antiseptic procedures.3,4,6
SD strategies also include the conscious use of products that are
suitable for the cleaning and/or disinfection of surfaces, as well as
the use of barrier protective coverings and no-touch disinfection
procedures.2
The current procedures in force to improve ergonomics and reduce
work related allergies comprise the adoption of products that are
fragrance free, environmentally friendly and with an activity level
certified in accordance with Standard prEN 14885 (Chemical
disinfectants and antiseptics – Application of European Standards
for chemical disinfectants and antiseptics). They also include the
employment of impregnated single use wipes and of single use
barrier protective coverings.3,7
BOX 1 - Clinical contact surfaces’
BOX 2 - Improper use
Clinical Contact Surfaces’ (CCSs) are defined by the Centers
for Disease Control and Prevention (CDC)29 as “surfaces that
might be touched frequently with gloved hands during patient
care or that might become contaminated with blood or other
potentially infectious material and subsequently contact
instruments, hands, gloves, or devices (e.g., light handles,
switches, dental x-ray equipment, chair-side computers).”
The disinfection with liquid solutions or impregnated wipes
of critical and semi critical instruments (that must undergo
sterilisation) made of metal alloys (e.g. orthodontic instruments)
must be avoided. The composition and low pH (<7) (Table 2)
of some surface disinfectants can compromise the surface
passivation layer and therefore trigger corrosion. Furthermore,
the manual procedure is dangerous due to the occupational
hazards of cutting instruments.
Contamination of Clinical Contact Surfaces
Contact with contaminated hands, aerosol or splatter causes bacterial
surface contamination in dental surgical units and over a much larger
area, such as operating rooms with dynamic instruments.8,9
Recent studies have shown that during surgical operations, no less
than 57 percent of the area spreading up to one meter from the
dental unit can be contaminated with blood.10 The luminol method
also demonstrated that in 58 percent of CCSs there were invisible
traces of blood.11
Moreover, methicillin resistant Staphylococcus aureus (MRSA) can
contaminate dental surgeries and approximately 8 percent of dental
surfaces.12,13
Significant bacterial contamination is present on various dental
surfaces (38 percent; of which 10 percent is of a polymicrobical
nature), curing lights (40 to 64 percent), intraoral radiographic
equipment (70 percent), telephones (61 percent when used by
dental staff compared to 26 percent when used by hospital staff),
and computer keyboards.14-18
It is suggested that CCSs must have an aerobic microbial
contamination of less than 2.5 CFU/cm2 (CFU = Colony Forming
Units).4
In Italy, the Standard Uni-Te 11408 indicates a surface microbial
contamination same or lower than 50 CFU/24 cm2 (≈ 2 CFU/cm2) for
the “clean zone”, and same or lower than 25 CFU/24 cm2 (≈ 1 CFU/
cm2) for the “sterile” zone used for sterilisation.19
Recent studies have shown that the mean bacterial surface
contamination varies from light level (2.8 CFU/cm2) in surgical
units,8 to moderate (12-40 CFU/cm2) after dental treatments.20
Furthermore, reported incidents (3.3 percent) have also resulted in
heavy contamination (40-100 CFU/cm2).
Decontamination drives approximately a 97 percent reduction of the
bacterial count. Following cleaning and disinfection procedures –
or after cleaning of an “easy to treat” surface, such as the smooth
surface of a dental chair – final mean values reached respectively 0.7
(93 percent of samples) and 0.8 CFU/cm2 (97 percent of samples).
However, any resulting incident produced light contamination values
(interval: 2.6 - 3.9 CFU/cm2) in both cases.
Microbial resistance
Organisms found on surfaces have different survival times depending
on the environmental conditions:
•
•
•
•
•
•
•
•
•
•
Respiratory viruses last from two to eight hours
SARS from three to nine days
HBV from one to six months
HCV from a few days to a month
HIV three days in a dry environment
S. aureus and MRSA from seven days to seven months
Candida from one to 120 days
Mycobacterium tuberculosis from a day to four months
Clostridium difficile spores for up to five months
Pseudomonas from six hours to 16 months.2,4,21
Bacteria and Candida can resist up to 10 days on computer
keyboards in dental clinics.18
The influence of humidity on microbial survival is a recently discovered
problem.22 The humidity level in dental environments is 20 to 50
percent; HBV can survive for up to seven days in 42 percent relative
humidity.21,23
Given this evidence, it does not come as a surprise that crosscontamination from an environmental surface was one possibility for
the first documented case of patient to patient transmission of HBV
in a dental setting.24
Without effective disinfection, dental surfaces can become a
potential source of infection considering that viruses with a “dried
out” lipid bilayer envelope or in the presence of an organic matrix are
more resistant to disinfectants.25
Risk of infection and surface contamination
The lack of definitive scientific evidence on the effects on human
health is not enough to assume an absence of risk caused by
CCSs. Certainly, the quantitative evaluation of the microbial risk will
make it possible to develop specific decisions applicable to dental
environments.26
However, operational and environmental settings can clearly
constitute a health dangers in dentistry. We are therefore forced to
adopt suitable procedures for customer and operator protection.7
Given MRSA’s involvement in surgical infections, it is a concern to
know that surface contamination with MRSA and its infective dose
are estimated at <10 CFU/cm2 and 4 CFU respectively.2,27
Guidelines and strategies
The 2003 CDC guidelines for dentistry specifies that after each
patient the surfaces must be cleaned and disinfected with a certified
low level (against HIV and HBV) or medium level (against TBC)
disinfectant, when the surface is visibly contaminated with blood or
other potentially infectious materials.28 The procedure is therefore
carried out in two phases.
The products selected in Table 2 do not allow the “one step”
procedure (simultaneous cleaning and disinfection). As the time
available for application and drying is about one minute, the 2008
CDC document recommends the use of approved products (i.e.
those compliant with EN Standards) with contact times lower than
the 10 minutes indicated in the previous guidelines.28,29
An attentive use of disinfectants is required to avoid the phenomena
of bacterial resistance and tolerance, reduced immune functions,
allergies and toxicities, and environmental pollution.3,7,28,30,31
Barrier protective coverings
The HTM01-05 guideline encourages the adoption of Disposable
Barrier Protective Coverings (DBPCs) on CCSs.29,32 In any case, the
surfaces of the dental unit and its accessories, worktops, halogen
lamps and radiographic equipment must be cleaned after each
patient and at the end of the working day.32,33
Purpose-made DBPCs are advantageous given the elevated levels
of contamination of suction units, radiographic equipment and curing
lamps.11,15,16 The covers used on devices (electronic, radiographic
equipment, etc.) must be replaced regularly, removed safely and
disposed as special waste in compliance with national laws.
Transparent food barriers can be adapted easily to dental surfaces
(Fig. 1) but it is important to remember that they can be contaminated
and small holes can form due to extension forces.34 It is therefore
preferable to use DBPCs appropriate to each different surface.
Whether the synthetic protective covers are able to effectively
perform as antimicrobial barriers depends on their component’s
hydrophobic characteristics (polyethylene). This has been confirmed
by several authors.12,27,34
In one maxillo-facial department, the use of barriers combined with
appropriate surface disinfection has contributed to the disappearance
of cases of MRSA infection.12
Some transparent barriers (transparent food grade films or commercial
protective covers), pulled perfectly tight, do not influence halogen
lamps’ emissions of light, or only cause non-significant modifications
from a clinical point of view in the models examined.35-37
Single use covers on water/air syringes or on dental chairs can only
limit the MRSA contamination.12,27 This partial isolation from MRSA is
probably due to the hydrophobic bacteria’s (such as Staphylococcus
aureus) ability to adhere to polyethylene.
Finally, Oosthuysen has highlighted the issue around how frequently
the covers must be replaced in relation to cost, environmental impact
and the high turnover of orthodontic patients.6
In my view, the decision depends on the degree of risk posed by
environmental contamination during diverse dental procedures,
for example, removal of orthodontic fixed appliances versus
the replacement of orthodontic elastomeric chains, particularly
considering the incomplete development of the immune system of
adolescents and their frequently poor oral hygiene.
1A
Disinfectants versus cleaners
There is currently an ongoing debate around the use of surface
decontamination products with a detergent action only, against
those with both a detergent and a disinfectant action.2-4,20,27
In terms of efficacy, it is undeniable that:
1. there is no surface disinfection without cleaning, and
2. cleaning (a reduction of inorganic and organic contamination
such as soiling and organic contamination) and disinfection
(inactivation of vegetative species) are terms that identify different
procedures and that require unequivocal definitions.7
There is a need to evaluate the lower costs and reduced toxicity
of detergent products versus disinfectants, against the products’
capacity to maintain contamination levels that are appropriate to
the clinical risk and national legal obligations. The biggest issues
associated with detergents arise from non standardised or ineffective
cleaning procedures, and from the microbiological contamination of
the detergents.2,3,38
Many research studies have highlighted the need for surface
disinfection as a control strategy.28,39 The surface disinfectants’
inability to perform their biocidal action seems to be primarily
caused by operator errors (choice of an unsuitable disinfectant,
failure to clean, incorrect dilution or dilution with contaminated
water, contamination during the transfer of the liquid) rather than
the microorganisms’ ability to adapt/acquired tolerance against the
products.40-41
Moreover, today’s most pressing problem is the compatibility
between auxiliary products (paper towels, rolls, etc) and the liquid
disinfectant. Auxiliary products made of cellulose or cotton can
contribute to trap and loss of 30 to 50 percent of QUATS, or can
influence the efficacy of other disinfectants.18,42,43
1B
1C
Fig. 1 Disposable Barrier Protective Coverings
The photo gallery demonstrates how the use of purpose
made DBPCs (photos 1A, 1B and 1C) gives a more
orderly and smart look to a dental office compared to
transparent food barriers (photos: 1D, 1E).
Appropriately positioned DBPCs are suitable to cover
CCS’s accessories, instruments, dental chair parts, or
office staff.
1D
1E
FIG.2 – Surfaces of: A) Zeta 3 wipes; B) SporeClear wipes and C) CaviWipes (Photo taken with Nikon Coolpix S51, enlargement with the Macro method)
Zeta 3 wipes Pop-up
2A
SporeClear wipes
Impregnated wipes
Sattar has recently examined the technology, advantages and
problems associated with the use of impregnated wipes while waiting
for a specific standard and appropriate protocols to be defined.7,44
The advantages of wipes are summarised in Table 1. Compared
to liquid disinfectants, wipes are made of inert materials meaning
that QUATS are not trapped and the biocidal actions guaranteed
by the combination of correct concentration of the product and the
contact time. It is essential to prevent the wipes from drying out and
manufacturers must guarantee the seal on their boxes for 28 days.7
Impregnated wipes are preferred when treating “difficult” surfaces
and to prevent the bacterial contamination recorded in 42 percent
of a number of surface disinfectant liquids (caused by refilling or by
contamination on the outside of the container).32,45 Unfortunately,
there is currently no information on the effects that products, liquids
or impregnated wipes with a disinfection action, high deterging power
and different pHs have on the operation of dynamic instruments.
Choice of surface disinfectant and wipes
The choice of the right disinfectant to use must be determined by the
examination of the efficacy of the product (spectrum of action and
contact time), safety data sheet and the need of personal protective
equipment, ease of use, information on compatibility, training on use,
and costs.46
Table 2 highlights some important information for the selection of the
“most suitable” disinfectant for dental offices. This study excludes
disinfectants based on hypochlorite and hydrogen peroxide
respectively due to problems with their metal material incompatibility
and high costs. It also excludes low cost disinfectants due to their
very limited efficacy, long action times and/or significant quantities
of solvents (for example, acetone), making them incompatible with
synthetic materials.
The products referred to differ from one another by one or more
characteristic, as stated in the manufacturer indications: spectrum
of action; contact times for infectious agents; compatibility with
different materials; biocompatibility and eco-friendliness; different
formulations; appropriateness for use in high efficacy and high
efficiency operative procedures (Table 1-2). It is advisable to use
disinfectants that are also active against MRSA and Candida, both of
which are involved in surgical and peri-implant infections. In dentistry,
the stability of the working solutions is not a discriminating factor,
with the exception of Rely+OnVirkon (stable for five days).
2B
CaviWipes
2C
The products’ (CaviCide, FD333, SporeClear, Unisepta Plus,
Zeta 3) spectra and action times are in line with the CDC 2008
recommendations29 and are certified in compliance with the relevant
EN standards. Only CaviCide and SporeClear are compatible
with synthetic materials and are active on biofilms.47 and Table 2 The
final choice comes down to the different dimensions of the wipes,
absence versus presence of fragrances, aesthetic disadvantages,
and, above all, on the careful analysis of the safety data sheet and
the risks arising from the use of these two products. The CDC
documents advise against the use of sporicidal surface disinfectants
or limit them to cases of bioterrorism, which are unlikely in dentistry.
Nonetheless, some spore bearing species seem to be present in the
dental field.28,29,48-50
Given that decontamination procedures are frequently carried out
on CCSs, it is preferrable to use disinfectant products that are
compatible and combined with efficient cleaning products. Zeta
3 Wipes and SporeClear wipes utilise a mixture of detergents and
microfiber wipes (Figs. 2A, 2B), while CaviWipes combines the
action of microfiber wipes with a differentiated topography (Fig.
2C) that renders them inert, and a detergent. Gold et al evaluated
six different disinfectants and detergent wipes according to their
efficacy in removing proteins, in lowering the bacterial burden, and
the force necessary to remove dry residues. CaviWipes has proven
to have optimum characteristics in all the evaluations carried out.51
The quantity of disinfectant contained seems to be optimal (0.016 g/
cm2) even for use on computer keyboards. Moreover, experimental
conditions (48 hours) proved the wipes’ long term disinfecting
efficacy.42
TABLE 1 – Advantages of single-use wipes soaked with disinfectant
The study compares a number of wipes for the cleaning
and/or disinfection of non critical surfaces in a two step
procedure, according to characteristics (surface topography,
mechanical characteristics, etc.) as indicated by the
manufacturer. The wipes are soaked in TNT and can be inert
and functionalised. The different surface topographies of the
CaviWipes, SporeClear and Zeta 3 Wipes are shown in Fig.
1 below.
Operational advantages
• Optimum release of disinfectant provided that they have
been sufficiently soaked to guarantee the contact time
appropriate to the treated area
• No errors associated with insufficient quantities or incorrect
preparation of the disinfectant (for example, dilution/
hardness and microbial contamination of the water)
• Usage on difficult surfaces, meaning those that are not
smooth and flat, but vertical (light switches), rounded, with
keys or knurling, etc.
• No problems associated with contamination caused by
the refilling of containers 32
• Minor problems of contamination of external packaging
can occur with non returnable packaging45
• Preferable for electronic devices
• Preferable for optical components (such as tips of halogen
lamps or magnifying lenses), where compatible
• Ergonomics suitable for the decontamination of the
handpieces for prophylaxis (for example, the non
autoclavable parts of PROPHYflex 3 by Kavo) and dynamic
instruments, where compatible
• Ergonomics suitable for the decontamination of the
multitude of vials containing dental materials that have
been touched with contaminated hands
• Ergonomics suitable also for the decontamination of
cables, cords and flexible connector tubes
• Useful for decontaminating the attachments and cords of
the handpiece holder prior to testing the dental unit water
lines
Occupational advantages
• Minor inhalation of and dermal exposure to components3
• Minor risks associated with flammability/spillage of alcohol
based liquid disinfectants
Ecological advantages
• Competitive costs also due to cost savings on the transport
of the liquid disinfectants
• Savings on the plastic containers
• Avoid or prevent the use of pressurised spray in compliance
with national laws
Another recent comparative study of five different types of
impregnated wipes based on the ASTM’s International Standard
method, demonstrated similar reductions in bacterial burden, but
showed differences in the transfer prevention of viable organisms
to neighbouring surfaces.52 To my knowledge, there are no similar
publications available for the wipes selected in Table 2.
Conclusion
In the future, there will be an increase in the use of the no-touch
procedures (vaporisation with hydrogen peroxide, HEPA filters, etc).
We will also adopt biodegradable protective covers, ultramicrofiber
wipes, nano technological and biocompatible disinfectants,
antibacterial surfaces and rapid systems to control environmental
cleanliness.2,53
The setting of specific guidelines is pivotal (protocols for refilling,
use of wipes, specifications for magnification systems, for dynamic
instruments and handpieces for prophylaxis, etc.), as well as
the development of transparent barriers and wipes suitable for
telephones and, above all, for iPads and tablets. This is true in view
of their growing popularity in the healthcare environment and the
restrictions imposed by the manufacturers on the use of disinfectants
on them.54,55
To conclude, it is important to remember that the success of surface
disinfectants, in terms of efficacy and dental area ergonomics, is not
just the responsibility of the person who chooses a product, or who
carries out the procedure, but also of everyone else who works in a
dental office.
TABLE 2 – Characteristics of some disinfectants in relation to clinical contact surfaces(a)
Manufacturer
CaviCide
Rely+On
Virkon
Zeta 3
FD333
Unisepta
SporeClear
Kerr Dental
Antec DuPont
Zhermack
Dürr Dental
Unident
Hu-Friedy
-
-
35.4%
62%
55%
-
-
0.7%
0.05%
0.11%
-
-
35%
-
-
Components and characteristics
Ethanol
QUAT or super QUAT (#)
0.27%
Isopropanol
(#)
17.2%
Mixture of QUAT and guanidine
-
Complex K+peroxymonosulphate
1-10%
0,1-10%
-
49.8%
-
-
-
-
Yes
Yes
Yes
No
No
Yes
11-12.5
2.6
9-11
6.5-7.5
5.8
4.9
3’
5’ (1%)
2.5’
1’
30”
1’
HBV, HCV, HIV viruses
2’-1’-2’
10’ (1%)
2.5’
30”
30”
1’
Non enveloped viruses
>3’
-
2.5’
1-5’
30”
1’
Mycobacteria
1’
20’ (3%)
2.5’
30”
30”
1’
MRSA
3’
yes
-
-
30”
1’
Candida/Aspergillus
1’
10’ (1%)
5’
1’
30”
1’
SARS-CoV
1’
yes
-
30”
30”
1’
Spores
no
10’ (1-3%)
no
no
no
1’
Yes
Yes
No/Limited
No/Limited
No/Limited
Yes
Yes and intended
for the type of wipes
and components
No
No
No
No
Yes (UK test)
No
Yes
Yes
Yes (liq.)
No (wipes)
Yes
Yes
Liquid disinfectant characteristics
Ready to use
To be prepared
Ready to use
Ready to use
Ready to use
Ready to use
and to be
diluted
Wipes characteristics
Ready to use
Ready to use(c)
Ready to use(d)
Ready to use
Ready to use
1’
30”
1’
5’
30”
1’
Detergents and/or solubilising agents
pH
Spectrum and times of action
(b)
Bacteria
Compatibility with synthetic materials
(47)
Action on biofilms
Fragrances
Virucidal activity
30”-2’
Bactericidal activity
1-3’
Tuberculocidal activity
1-3’
5’
30”
1’
3’
5’
30”
1’
Butyl rubber
protective gloves,
nitrile rubber gloves,
penetration time
>60’; material
thickness 0.1 mm;
safety glasses EN
166
Category III work
gloves (EN 374) and
hermetic protective
glasses (reference:
Standard EN 166)
Category III work
gloves (EN 374); for
example
nitrile 0.1 mm thick
for contacts < 30’;
Glasses with lateral
protection EN 166
Protective gloves
suitably resistant
to chemical agents
in compliance with
Standard EN374;
avoid contact with
eyes
Not indicated in the
safety data sheet
Rapid evaporation,
protein/blood
fixation
Faded stains on metal
trays and transparent
screens. Effect of the
elevated detergent
action on dynamic
instruments (?)
Fungicidal activity
Personal protective equipment
required for hands and eyes
(N.B. the resistance of latex gloves to different
disinfectants can vary from 10 minutes to a
few hours)
Issues
Risk phrases
(R-, H- and EUH)
(those of specific interest are highlighted
in bold)
Not available
Rubber gloves and
close fitting safety
glasses
Slight speckling
on metal trays with
wipes
Oxidising and
corrosive action on
metals and alloys,
on electronic and
dynamic devices
Rapid evaporation,
protein/blood fixation
Rapid evaporation,
protein/blood fixation,
overall costs
(including purchase
of Hygowipe,
supply and
maintenance)
to be evaluated
carefully
Acute tox. 3 (oral);
Acute tox. 4 (dermal
and inhalation, oral);
Aquatic chronic 2;
Eye irrit. 2; Flam. liq.
3; Skin irrit. 2; STOT
SE 3: H225; H226;
H301; H3012; H312;
H314; H315; H319;
H332; H335; H336;
H411
R 8; R22;
R34;R36;
R36/37/38; R36/38;
R37/38;R38;
R41;R42/43;
R52;R53
Flam.liq 2, flam.liq
3, Acut Tox. 3; Skin
corr. 1B; Eye irr. 2;
STOT SE 3; Aquatic
acute 1; Aquatic
chronic 3; H225;
H226; H301; H314;
H319;H336;H400;
H410;H412
H225; H226; H301;
H314; H319; H336;
H400; R10, R11,
R22, R34, R36,
R50, R67
(a) Information and MSDS downloaded from manufacturers' websites or taken from available hard copy,
updated on 04/12/2015
(b) Reported only for indicative pathogenic agents, according to Spaulding
H225; H302; H314;
H319; H335; H336;
H400; H410; R 11;
R 22; R 34; R 36;
R 50/53; R 67
(c) Zeta 3 wipes Total
(d) Product informations not available from website www.duerrdental.com
H225; H302; ; H312;
H314; H317;H318;
H319; H336; H351;
H372; H373; H400;
H410
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