Although the cleaning and sterilisation of instruments is not considered the most exciting aspect of a dental practice’s work, it is one of the most important, since the inability to adequately clean and sterilise instruments should in theory cause the closure of the practice. According to the CQC, over 10 per cent of practices inspected during the first year of regulation failed to comply with Department of Health guidance, with some practices disregarding even the most basic levels of hygiene and cleanliness.
With the increasing visibility of compliance, practices not only face the real possibility of having to close their doors but also have to consider the impact of the negative publicity caused by a poor CQC inspection. However, most of the infection control guidance is relatively easy to follow, given the right cleaning products and systems.
The cleaning of soiled dental instruments prior to sterilisation is the first essential part of the daily routine in order to reduce the risk of transmission of infectious agents and to remain compliant with HTM 01-05 or other local regulations. The detergents used to clean instruments in practice contain surfactant molecules that have two important components: one end of the molecule repels water (hydrophobic), while the other end attracts water (hydrophilic). When these molecules come into contact with soiled instruments, the hydrophobic end becomes attracted to the soil and surrounds it, whilst the hydrophilic end draws in the solution. This soil is suspended, by the right blend of surfactants and other cleaning components, preventing re-deposition on the cleaned surface. One of the challenges faced by many practices when cleaning instruments is having the ability to clean them quickly after use. As we all know from our own domestic experiences, if soiled equipment is allowed to dry out prior to washing, any remaining material can become difficult to remove. The same is true of the residual protein left on instruments after use in the surgery, the longer instruments are left before cleaning, the more difficult the process is. However, depending on the size of the practice and number of surgeries, it is not always possible to clean instruments immediately and this can make the removal of contamination extremely difficult. A further problem is highlighted by the fact that oral tissues contain salts that can both discolour and cause instruments to rust, thereby increasing the likelihood of mechanical failure.
Where cleaning immediately after use is impractical, the guidelines recommend that instruments are pre-soaked in either water or in a specifically designed foaming solution as an additional method of ensuring cleaning processes are effective.
HTM 01-05 Section 3.5 states: “Instruments cleaned as soon as possible after use may be more easily cleaned than those left for a number of hours before reprocessing. Where this is not possible, water immersion or the use of a foam spray or gel intended to maintain a moist or humid environment are thought useful in aiding subsequent decontamination.”
This recommendation supports the paper published in 2007 by Lipscomb, Pinchin, Collin and Keevil, which found that pre-soaking instruments significantly reduced (by up to 96 per cent) prion-infected tissue contamination. The easiest method of keeping soiled instruments moist is to spray them with a pH neutral water-based solution that prevents blood and tissue drying onto surfaces. The non-drying component, or humectant, in the liquid helps to keep the soil moist while surfactants loosen any debris and start the decontamination process straight away. The recommended spray is low foaming and contains a corrosion inhibitor to prevent any possible staining on metal surfaces. Once the instruments are ready to be cleaned the spray is simply rinsed away with water.
There is now a wide selection of detergents and products designed for the cleaning and maintenance of dental equipment. Modern dental detergents are designed to make the whole cleaning process quicker and easier and many are specially formulated for either manual or ultrasonic cleaning, reducing the need to buy and store additional products for practices that use a combination of cleaning methods. As technology has advanced so the effectiveness of detergents has increased, for example enzyme-based cleaners are available for both manual and ultrasonic cleaning methods, using the presence of an enzyme blend to act as a biological catalyst. This speeds up the chemical breakdown of proteins present into smaller units that can be more easily removed from the surface of instruments.
For those using washer disinfectors, a low foam, low residue, non-caustic detergent is the best solution, coupled with a rinse aid that allows rapid drying, reduced water spotting and leaves a clear ‘sparkling’ finish that visually reinforces the infection control credentials of your surgery. Both detergent and rinsing agent must be formulated to operate effectively in either hard or soft water areas, as this helps to prevent scale build-up in rinse jets and pipes and therefore reduces the likelihood of future maintenance issues for this essential equipment. As stated in HTM 01-05 17.11: “The detergent should be chosen for its cleaning efficacy and its compatibility with the water quality.”
The importance of making the right choice of suitable, effective detergents for your practice must not be underestimated as making the right selection can save time, money and provide peace of mind for those with decontamination responsibilities. Detergents must be suitable for each specific cleaning process, have no adverse impact on the instruments, equipment nor the environment and be completely safe for staff and patients alike. Efficient, correct and thorough cleaning remains the most basic foundation of infection control within the practice and a robust system that advocates the use of effective cleaners is the first step in making decontamination one less thing to worry about.