Surface Disinfection & Operatory Turnover – What Do We Know Now?

There is a vast array of information regarding how dentists should respond to COVID-19. We are working overtime just to be aware of the various guidelines and recommendations from the American Dental Association (ADA), the Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA).

Thankfully, infection control has been a part of our practice lives. The best infection control practices evolve and are based on an identified danger. They provide a level of safety for team members and patients and are intended to maintain our level of health as we interact with family and spend time with friends.

Sprays, wipes and fog

Much of infection control relates to barriers such as masks and gloves, sterilization packages for autoclaved instruments, and chemicals. But even then, there may be risks with the barriers themselves.

For example, Cavicide, a traditionally popular surface disinfectant, has health-related warnings. Its Material Safety Data Sheet (MSDS) states it has been shown to cause respiratory tract irritation and recommends the use of respirators and gloves. Under California Proposition 65, Cavicide is identified as causing cancer, birth defects, or reproductive harm.

Now, a new product, Cavi-1, has addressed the concerns with Cavicide and is available in spray or wipes. Another product, Optim 1, is touted as another alternative to Cavicide that doesn’t irritate the respiratory tract, but there are questions as to its effect over time on electronics or the film it leaves on dental equipment.

Fogging has been recommended as a method to combat health concerns related to aerosols, which are created by treating dental patients. Hypochlorous acid (HOCl) is a safe and practical disinfectant with a predictable ability to work on the coronavirus.

When it comes to disinfecting surfaces, the length of time a chemical is in contact with a surface is critical to its effectiveness. Research published in the journal Applied Environmental Microbiology shows HOCl solutions at 20 parts per million have demonstrated the ability to decontaminate virus-containing surfaces with 10-minute contact time. Dentists can make their solution, which isn’t at all practical, or buy a premade concentrate and use a fogging device to spread the disinfectant throughout an office.

But what are the potential concerns with using HOCl? According to an article in the British Dental Journal, the shelf-life of HOCl is approximately two weeks. It is also susceptible to sunlight exposure, is less stable when in contact with air, and when the temperature of the solution is above 77-degrees Fahrenheit (25 C).

Ultraviolet light

What is drawing the interest of Australian hotels like the Park Hyatt Sydney or the Four Seasons Hotel Sydney for surface disinfection? It’s floor-to-ceiling, chemical-free disinfecting germicidal ultraviolet light.

Working with germicidal ultraviolet light is also a best practice for hospitals in Saudi Arabia. They have been vigilant in working to protect against the coronavirus long before COVID-19 became a pandemic because the Arabian Peninsula was the area of the world hardest hit by the Middle Eastern respiratory syndrome (MERS) coronavirus first reported in 2012.

Some places in the U.S., such as the Space Needle in Seattle and Beachbody, the health and fitness company that produces home exercise videos like P90X, are working with Surfacide. At Beachbody, consider the turnover of people coming in and out of the workout studio — production crew, content creators, editors — and the level of safety provided through a chemical-free disinfectant.

Ultraviolet light might sound cutting edge, but according to public health reports, it has a long history of use in the U.S. dating back to 1877 … it’s been used to protect against the spread of measles and tuberculosis, in addition to coronaviruses

It is important to understand there are several types of ultraviolet light available on the market and used in a variety of situations. Specifically, the UV-C light is effective at killing the virus, as well as bacteria and fungus, with ease.

The technology available with Surfacide UV-C includes the ability to automate reports on how long the ultraviolet light was in use, and in which room it was used. The system can also detect the effectiveness of the light bulb to verify its efficacy. Before disinfecting, the triple emitter system can laser map the operatory, hallway, bathroom, or other areas to be disinfected and plan for the appropriate amount of exposure to its ultraviolet light.

But does ultraviolet light truly disinfect? How strong is the evidence behind germicidal ultraviolet light? A University of Iowa investigation demonstrated a MERS coronavirus kill rate of 99.9% after five minutes of exposure to the Surfacide UV-C system. The research evaluated a whole-room scenario with multiple emitters to minimize shadows and the distance the ultraviolet light traveled.

Faxton St. Luke’s Healthcare in Utica, New York, shared data focused on Clostridium difficile (C. diff) before working with the Surfacide system and following the 2013 implementation of germicidal UV-C showing a significant improvement. Dentists are likely not working with C. diff in the operatory, but the point is, if ultraviolet light is effective against the spore that carries C.diff then it can certainly be effective now and for what could come in the future.

Ultraviolet light might sound cutting edge, but according to public health reports, it has a long history of use in the U.S. dating back to 1877. The applications, the technology, and the protective measures have changed significantly since then, but it’s been used to protect against the spread of measles and tuberculosis, in addition to coronaviruses.

UV-C works for me

Working with the most recent information available for the Surfacide triple emitter germicidal UV-C technology, there are a few interesting points of interest.

The life span of the light bulb is tested to be 16,000 hours. The smart power relay boards of the Surfacide system are designed to use the least amount of power required to maximize the effectiveness of the ultraviolet light.

At my practice, we’ve been using the Surfacide UV-C Triple Emitter system in our office since July 2020 and have received positive feedback from several patients and others who have visited our facility.

It was surprising to me how well some of my patients were informed regarding the different types of ultraviolet light knowing full well it’s the UV-C that is effective at eliminating the pathogens.

The best part about having the three towers in the office is they visibly communicate to patients a level of protection that at least some of our patients are looking for in a dental practice.

Vaccine and risk tolerance implications

The goal of disinfecting surfaces and other protection protocols is to keep people safe as they return to an altered version of their regular activities. But there is a wide array of thoughts and opinions about the pandemic and how it will play out and every one is different, which makes our job even harder.

According to a vaccine distribution framework released by the National Academies of Sciences, Engineering, and Medicine sponsored by the CDC and the National Institutes of Health (NIH), dentists and dental hygienists are essential health care workers who should be afforded early access to a COVID-19 vaccine due to the risk related to the proximity with which we treat patients. The report, released on Oct. 2, will be considered as the federal government determines how a vaccine will be allocated in the U.S.

Just like disinfecting, there are implications to consider when a vaccine is provided to dental professionals. How will getting a vaccine or not getting a vaccine impact our practice? How many unvaccinated patients, whether by choice or due to availability, will come into our offices?

Above all, risk tolerance is an important yet confounding variable as we navigate the gray zone of what is acceptable for a close-knit practice team. Then there’s the risk tolerance of people who regularly come in and out of our office, e.g., the delivery person, laboratory couriers, equipment maintenance providers, building maintenance, and the nighttime custodial crew. Accounting for the risk tolerance of such a wide range of people is confusing, yet crucial because it can alter the course of a practice.

To move forward, do we have all the information we need to decide on how to create a safe environment that is accommodating for everyone — the practice team, the patients, and other visitors?

Douglas G. Benting, D.D.S., M.S., F.A.C.P. is a member of Spear Resident Faculty.

References:

Block MS, Rowan BG. Hypochlorous Acid: A Review. Journal of Oral and Maxillofacial Surgery. 2020;78(9):1461-1466.

Park GW, Boston DM, Kase JA, Sampson MN, Sobsey MD. Evaluation of liquid- and fog-based application of Sterilox hypochlorous acid solution for surface inactivation of human norovirus. Applied Environmental Microbiology. 2007;73(14):4463-4468.

Rossi-Fedele G, Dogramaci EJ, Steier L, de Figueriredo JA. Some factors influencing the stability of Sterilox, a super-oxidised water. British Dental Journal. 2011;210(12):E23.

Bedell K, Buchaklian AH, Perlman S. Efficacy of an Automated Multiple emitter whole-room ultraviolet-C disinfection system against coronaviruses MHV and MERS-CoV. Infection Control Hospital Epidemiology. 2016;37:598-599.

Reed NG. The History of Ultraviolet Germicidal Irradiation for Air Disinfection. Public Health Reports. 2010;125(1):15-27.