The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
Episode #7 Environmental Infection Control in Dentistry
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Have you ever wondered if the disinfectants you are using are effective against COVID-19? This timely podcast will identify CDC's latest infection control guidelines and how you can audit whether your product is on the EPA's N list. Stay in the know when it comes to environmental infection control so you can protect your patients and fellow team members.
Welcome. I'm Leslie Cannon. I'm Mary Gavoni. I'm Linda Harvey.
SPEAKER_00I'm Olivia Juan, and together we are the Compliance Divas. Welcome to the Compliance Divas podcast. We bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please subscribe to the Compliance Divas podcast through your favorite channel or on our website, the compliancedivas.com. Resources that we mentioned can be found on the website. I'm Olivia Wand, and I will be your moderator today. Today's topic is environmental infection control in dentistry. Now, more than ever, we have a raised awareness about infection control in light of COVID-19. Have you ever wondered about the efficacy of the products that you are using for kill claims against SARS CoV-2? Let's talk to our fellow divas about this topic. Leslie, can we start with you? What type of guidance is available for our listeners about environmental infection control?
SPEAKER_03Well, first of all, Olivia, the CDC Guidelines for Dental Settings that was published in 2003 is an excellent document to refer to. And I like to call that the Bible for dental infection control. And not only does it have great information on how to, but it also has information on there's a chart called Appendix A, which gives you an idea of the levels of disinfection for environmental surfaces and the pathogens or organisms that it kills. So for example, sometimes people say, Oh, I want an intermediate level disinfectant, but they don't exactly know how to look for an intermediate level disinfectant. In dentistry, most of our products that are considered to be intermediate level have the words tuberculosidal kill claim on them. So in looking for your dental catalog or when you're ordering, if you wanted to go with an intermediate level disinfectant, you would ask for a product that is a tuberculosidal type of product. Now, there's another document that I'm especially fond of that was published by CDC in 2016. And it's the CDC checklist and summary. It highlights the key points of the 2003 guidelines. It uh actually summarizes everything so it's easy to read. There's about 22 pages versus the 76 pages of the 2003 guidance. And what's very cool about this particular document is not only does it have a checklist for CDC recommendations, including environmental infection control, but it also has resources that you can click on. And the best part, it comes in a mobile app. So that's a way that someone can stay up to date with the most current information. And there's one other resource that I actually almost forgot to mention, and that was the OSEP guidance for COVID-19 in dental settings. That's a document that was created last year for COVID-19, and that provides more information on environmental infection control along with links that people can use.
SPEAKER_00Wow, that's so helpful, Leslie. And once again, we'll have all of those links that you referred to on the website. That will help our listeners so much time in researching for those guidance sheets. Linda, what would you say is helpful in regards to the EPA and the List N? Can you talk to our listeners a little bit about that? Yes, absolutely, Olivia.
SPEAKER_02The List N is a fairly new research tool that our listeners can use to research the products they're using in their practice or research a particular product they're thinking about buying to use as a service disinfective. Because with this N list, you're able to research to determine if your product is actually effective against SARS-CoV-2. And there's a little background on this list that I found interesting. Back in January of 2020, before SARS was just becoming uh known all around the globe, SARS-CoV-2, the Eviral Protection Agency activated its emergency viral pathogens guidance for antimicrobial pesticides. And this was beginning to look at this emerging viral pathogens, you know, which was of course SARS-CoV-2, it's right in that category. And then in March of 2020, last year, it actually released the initial N list. So dental team members can search on the N list or list in. Typically, what I do is it's easier for me to do just a broad Google search, put in the key letters, EPA, and then N list or list N, and you'll find that one of the first links that comes up will take you right to this page. So it's easier to find it for me via a broad Google search than just trying to navigate through the EPA entire website. But in looking at trying to determine if your product is on this list to see if it's effective against SARS CoV 2, you need to look at the registration number on the product that you're using. And there's different sets of numbers on the products that we're using. And sometimes the registration numbers are longer and maybe have two parts, two different sets of numbers, and sometimes have three sets. And any numbers that have two parts are known as the primary registration number, meaning that is the manufacturer of that product. And product registration numbers that have three numbers or three parts to them, three a series of three digits, like one, two, three, four, dash, one, two, dash, one, two, three, that's a series of three. That's a supplemental distributor product. So that means that product has been white labeled by a manufacturing company or a dental supply company and they're selling it as their house brand, much like when we go to the grocery store and we find brand names in that grocery store chain. So if you search by a name that happens to be the name on a three-part supplemental distributor product, you won't find that name of that product listed on the end list. And you'll get worried. You'll think, oh, my product's not approved. It doesn't kill SARS-CoV-2. What am I going to do? So it's important that you know to research the product using the EPA registration number. And also another piece to remember is that even though products that are listed on this list in, it does not mean that the Environmental Protection Agency has provided any endorsement for these products. And then last but not least, I'd like to remind our listeners that it's always important that you follow, read, and follow the manufacturer's instructions for use for accurately using your product of choice.
SPEAKER_00Wow, Linda, that is so helpful. You know, I remember years ago assisting a client who was actually disciplined by the dental board because they were using a product like pine salt to disinfect their environmental surfaces. And obviously, this was way out of compliance. And part of their discipline, in addition to paying the fine, was uh 12 hours of training. So, Mary, can you talk to us about training and why it's so important?
SPEAKER_01Absolutely. And Linda, that was such a great explanation about the EPA registration numbers. So I hope that our listeners appreciate your sharing your knowledge on that. And I want to add one more thing to that because in the early days of the pandemic, when we were hearing a lot about these list and surface disinfectants, there were many products that a lot of practices had been using in the past that initially didn't have that EPA list N designation. And the many users were either led to believe by other product manufacturers, or they assumed that if it wasn't on List N, they couldn't use it and they had to switch disinfectants. And last spring, late last spring, the EPA issued a clarification statement that said that if a facility was using a product that had a higher level of efficacy, in other words, it was certified through the EPA to kill microorganisms that were more resistant than the SARS-CoV-2 virus, then it met the criteria for List N. So if it if it's more broad spectrum, and if you looked at the hierarchy of resistance of disinfect or of microorganisms, um a coronavirus, which SARS-CoV-2 is, is really at the bottom of the food chain. It's very easy to kill, doesn't have a lot of resistance, whereas our gold standard in dentistry, per the CDC guidelines that Leslie mentioned earlier, um, says an intermediate level and tuberculosidal is our benchmark. So that's what we have used routinely. So if you're using a tuberculosidal disinfectant, you're good to go. Now, if you don't know if your product is tuberculosidal, you can certainly look on the label to see if mycobacterium tuberculosis is listed. But you can also go to list B as in boy from the EPA, and that's where the tuberculosidal disinfectant list lives. So this is more information than we probably ever wanted to know about our disinfectants. And sometimes we sort of we get into the routine, this is what we use, this is how we use it. But Linda alluded to the fact that you need to follow the manufacturer's instructions. There are products that are one-step products, meaning if there's no blood present or no anticipated blood to be present, maybe you simply did uh an evaluation on a patient, you just looked in the mouth and rescheduled them and didn't do any treatment where there would be blood spatter. You can do a one application and you're done. But that doesn't mean that it applies in all settings. If you were doing operative dentistry where you could assume there was some blood, those products are really still two-step products, meaning you wipe or apply the disinfectant first to clean, and then the second step reapplication of the product is to disinfect. So those are the types of topics that need to be included in training. If you switch products, you should always have a mini training session with your team so that everybody understands the potential differences between one product and another, what's the contact time. Um, and typically the contact time that we pay attention to for our products is what is the kill time for TB. So it may say on the label for a product it kills um SARS or it kills HIV in one minute, but we really need to look at what is the TB kill time and making sure that everybody on the team really understands how to read that label. What are the instructions, for example, for PPE? What is recommended for PPE when you are using the product? And it one of the um, I think resources that many people don't take advantage of enough are resources actually from the manufacturers of these products. Some of them have video training about how to use their products, um, some of them have safety tips, um, again, about PPE and so forth. And we've evolved, in my opinion, thankfully, into using more wipes than sprays because spraying disinfectants, we know, has caused some respiratory issues for dental team members. But make sure that everybody on the team knows that in between uses, we close the lid back up so that the disinfectant, the alcohol in the disinfectant doesn't um um evaporate and dry out the wipes. And then periodically, again, with everything, the cover fastened down, you tip the container upside down and let the top of the wipes resaturate. So there's lots of good tips that you can get from the manufacturers on the label that teach you how to use it. And you know, you've got this great prop in front of you in a training session that you know, you just go through and and read the label, simple, simple as that. So hopefully those are some good issues. Yes, Linda.
SPEAKER_02Oh, Mary, I have to tell a story. Um, last year when a client who um during the shortage of all these wipes found a non-healthcare uh warehouse locally and bought some generic wipes there. And I believe they were more for just environmental cleaning and general office spaces and things like that. And he was so proud to show me when I was on site, look what I found this new resource. And there's 800 wipes in this tub, and they were very large wipes. They were like eight inches by six inches. And the big print, as I often say, is you know, the big print giveth and the small print taketh away. So the big print said, you know, kills 99.9% bacteria on contact. And there was an EPA registration number, but it did not meet any of the criteria that you just mentioned, Mary. It didn't kill TB, didn't have a tuberculosidal kill claim, it wasn't on the list N. And so I kindly had to pry those out of the doctor's hand and say, you could take these home and use them in your wood shop or in your somewhere else, but not in your dental practice on any, you know, clinical contact surfaces. So there's so much misum information and misunderstanding and trying to work with um the shortages.
SPEAKER_01And so thanks, Linda. Uh and we've all had those similar stories. And one of the things that I didn't mention is misuse of disinfectants by making up your own disinfectant wipes. Um, and I come from the days, and probably all of us do, of when we used to use isopropyl alcohol on even just a two by two to wipe down the bracket tray and wipe the hand pieces and so forth. And so we've all done this. We got a big apothecary jar or container, and we stuffed as much gauze in as we could, and then poured from the gallon jug of uh isopropyl alcohol. And isopropyl alcohol can disinfect, but it evaporates too quickly to do any good, and it um also is not a good cleaner. So that's why it's a component of many disinfectants, but it's not used straight as a disinfectant, and it is not affected by um cotton fibers or or gauze fibers, but the other disinfectants are. So if you take three by threes or four by fours and you put them in a container and pour your product over the gauze to saturate them, they're probably good for several hours, maybe a workday. And there's actually a study quoted in the CDC 2008 guidelines on sterilization and disinfection that shows that after several hours of a disinfectant being soaked or gauze being soaked in a disinfectant, that there actually were gram-negative bacteria growing in the container. So the fibers in the gauze will bind up the active ingredients and make it no good. Now, wipes, of course, are fiber as well, but these disinfectants have been tested for efficacy and long-term efficacy by the EPA to make sure that they aren't inactivated. So making up your own wipes. And I've heard the stories people are using tea tree oil and some really creative natural products, but don't go there. Just don't go there. It's too big of a risk.
SPEAKER_00Great information, ladies. Uh, I well remember those days working chairside. Uh, to see the wipes come along was such a great thing because we were concerned for our respiratory safety using the sprays, but great information, ladies, on using the wipes correctly. Leslie, we would like to know more information about alternative disinfection methods, especially since the COVID guidance for dental settings mentions this very topic. What can you tell us about alternative disinfection methods?
SPEAKER_03Well, thank you, Olivia. I'd like to just first state that during the beginning of our pandemic, um, we had an increase of calls to the poison center by 20%. And so sometimes people were not either following the directions or mixing chemicals inappropriately. There was uh not well-ventilated areas and uh storing the chemicals in a way that they could be hazardous. So we want to make sure that uh when we're looking at alternative methods of disinfection, that we follow all manufacturers' directions. The biggest question that I got from people during the uh pandemic was what about hypochlorous acid? Can we use hypochlorous acid for uh fogging the air? And hypochloris has been a product that's been around for quite some time, but it has been actually approved as a surface disinfectant. So when we're talking about using it in an alternative way, number one, it violates the manufacturer's instructions for use, but number two, we're not quite sure if there's going to be health issues as a result or uh any other issues, corrosiveness on surfaces, that sort of thing. So I uh referred to, and I'll make this reference available as well for the resources on podcast, the American Association of Oral and Maxylfacial Surgeons published a great article in September of 2020. It was called Hyperchlorous Acid a Review. And it's Michael Bloch and Brian Rowan that wrote this particular uh article. And to summarize it, the main points were uh number one, uh EPA has registered hyperchloris as a surface disinfectant, and it's on the list for being list N for effective against SARS-CoV-2. It's used in the food industry and for wound care. It's inexpensive, and you can uh purchase it commercially so it's ready to use, or you can make it on site yourself or brew it yourself, as you sometimes hear people say. It's a powerful oxidizing agent. So all of those are benefits, but uh contraindications, it does have some stability issues. It's affected, the shelf life is affected by sunlight, half-life increases with decreasing pH. It's less stable when it's uh exposed to UV, which some people are using UV radiation or UV lights, uh sunlight and air over uh air temperatures over 77 degrees. And then probably the biggest component of this for using hypochloris uh as a rather than surface disinfectant, but using it uh to fog the air, the fogging process can actually alter the physical and chemical properties of the disinfectant. So while FDA has had clear or EPA has cleared this as a disinfectant, FDA has cleared various different machines for fogging. But the foggers are really designed for surfaces. So if you can imagine, let's say in a factory, so the food industry, they factory, they have conveyor belts, they have canning processes, the fogging would get lots of surfaces and disinfect surfaces that would be difficult for someone to clean and disinfect by hand. So, really, that's kind of the story behind fogging. But FDA also, while it has a mission has approved different machines for the fogging process, it does not recommend spraying humans with aerosolize disinfectant. And there's no data that demonstrates that this method is effective in treating or reducing the spread of COVID-19. Spray disinfectants and uh uh these types of uh products that we use for environmental infection control should never be used on human or animals because they are intended for hard, non-porous surfaces. Now, if you spray people with a disinfectant, it actually can cause uh eye and skin irritation, bronchial spasm following inhalation, and even gastrointestinal effects such as nausea and vomiting. So the bottom line is that if you're going to use one of these alternatives, use it the proper way, use it according to the manufacturer's directions. We are talking here about environmental surfaces, so we're we're not talking about um containing aerosols in the air. And that's what I think probably the biggest takeaway is that uh we could be using chemicals improper. And uh many people scrambled to find alternatives because of the disinfectant wipe shortage, which wasn't necessarily the chemical that's that's the shortage problem, it's the substrate wipe itself that was the shortage. And so there is plenty of our favorite disinfectant available in the liquid form. Let's use it the right way. And um, I always subscribe to the spray wipe spray method of cleaning surfaces. If you're concerned about breathing in the aerosols from a disinfectant, you can dial your spray bottle nozzle so that it's a heavier droplet. It'll fall more quickly to the surface. And of course, if you're wearing a mask, hopefully you're protecting yourself from what you might be inhaling in a treatment room, including these droplets from the uh aerosols that might be generated. And of course, you know, with the two by two and four by four, uh soaking a disinfectant gauze at the time of use uh would also be another way to make sure that we're cleaning our surfaces uh properly rather than storing. And of course, always close the lid, as Mary said, on those disinfectant white tubs when you have them.
SPEAKER_00Wow, great information, Leslie. Thanks for that information. I wanted to supplement all the great information that you shared that you know, the guidance is pretty clear that the efficacy of alternative disinfection methods such as ultrasonic waves, high-intensity UV radiation, and LED blue lights against SARS-CoV-2 is not known because they don't routinely review the safety or efficacy of pesticidal devices. And also, I do want to mention that CDC does not recommend the use of sanitizing tunnels. So it's it's important, as you stated, Leslie, that we have to look at the guidance to align our practices with the correct product lines. Mary, what can you share?
SPEAKER_01One additional thing which made me think about Leslie's comment about the using spray wipe spray. I always called that in the past the gospel according to John Molinari, because he was the one who taught us what spray wipe spray meant. And you know, you spray and you wipe to clean and you spray again to disinfect. And um Biotrol, which is um part of Young Dental, makes the neatest little um squirt top dispenser for a spray bottle. They'll fit on pretty much any manufacturer's spray bottle. They cost just a couple of dollars, and they screw onto the top. It's it's kind of like on a water bottle that has like a pop-top opening on it. And it's got a little meter or a baffle inside. So once you tip the bottle over onto your gauze, it only dispenses out a certain amount of solution at one time. So you can't like waste solution or oversaturate the gauze. And I found it to be a good alternative if people are still having issues getting wipes. So that's my little helpful hint for today.
SPEAKER_00That's a great tip, Mary. Thank you. And now I'm wondering, you know, with people that might be changing their product lines or looking at different product lines, or even assuring the compliance with what they're using, Linda, what can you share with our listeners as how it relates to the chemical inventory and the safety data sheet?
SPEAKER_02I mean, those are two important topics because as we've been having this very thorough and of course reminiscing about our days when we were practicing and what we did with disinfectant surface disinfectants during different time frames, we really can't have this discussion of environmental disinfectants and their chemical ingredients without circling back around OSHA's hazard communication standard, because this is a federal standard in which employers are required to ensure that their employees have both the need and the right to understand the chemicals in the workplace and how to protect themselves from these chemicals. And we do that through two mechanisms under this standard. One is the chemical inventory list, and the other is the safety data sheet, among other requirements of this standard. The chemical inventory list, I've found over the years has been one of the most misunderstood requirements of the hazard communication standard. Many times over a dental team member and um or maybe even a sales rep feel like that just the chemical inventory is a list of the products that you buy from a particular company or vendor. And actually, when you look at the hazard communication guidance document, which we will include in our resource section, on step two under training, it talks about the fact that you must have a list of the chemicals and the products that you use. It's very specific there. So it's not a downloading your purchase items from your favorite vendor and calling that a chemical inventory list. And then further, when you look at OSHA's requirement to have this chemical inventory list, it's important that when you research documents on the OSHA website itself, that we're not looking at grant materials and grant projects that were performed or conducted because of research monies given by OSHA, but looking at specific OSHA guidance and interpretation letters. So I'm also going to make sure that we have another resource on our website that gives everyone the list of what should be included on a chemical inventory list. And that is the chemical name, the CAS number, the common name of the product, synonyms for the name of the product, the product mixture if it's applicable, and then of course the percentage of the ingredients. This is a very detailed list that has to be compiled by dental team members. And we begin to look at this information from and gather it from the safety data sheets, the SDS sheets. We've been using the safety data sheet since 2012 when that transition period happened, when OSHA adopted the United Nations globally harmonized system for classifying and labeling chemicals. And if we recall, those of us that have been in dentistry for a while, that was a four-year transition period. And so we have the safety data sheet that gives us all this chemical information. The SDS sheet now is very organized. It's extremely easy to read. There are 16 required sections, and section two always has the hazardous ingredients, while section eight always has the required PPE. So I think that will point our listeners into the direction, Olivia, of how to find that information and how to keep it current in their practice.
SPEAKER_00Well, thank you, Linda. That's great information. You know, our fellow divas, we're working so hard behind the scenes to help everyone get into compliance. And this has been a great topic for us on environmental infection control. So we bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please remember to subscribe to the compliance divas podcasts through your favorite channel or on our website, the compliancedevas.com. Any of the information we mentioned, the resources will be linked on the website to save you time. Thank you once again.