Fools' Paradise?
Much has been said lately about the good old days of orthodontics--the Golden Age of Orthodontics. Certainly it was a time when there was an abundance of patients and when orthodontists' busyness was nearly optimum. But not everything was golden about this era. In one important respect--instrument sterilization--orthodontists were living in a fools' paradise.
In the '50s and '60s the standard procedure was to wash the instruments in soap and water and then wipe them with an alcohol sponge. If the office was high tech, the instruments might be soaked for 10 minutes in a week-old solution of Zephiran chloride. It has taken the AIDS and hepatitis epidemics to focus the collective attention of health professionals on asepsis, but it is an emphasis that is long past due.
Hepatitis and AIDS are deadly diseases that are no longer geographically or socially isolated, and they are transmissible through body fluids. There is no doubt that the hepatitis virus can be passed along through saliva contamination. And although it is currently doubted that the AIDS virus can be transmitted similarly, how many of us would willingly expose ourselves to the risk?
We owe ourselves, our staffs, and our patients the maximum protection possible. I recently read of a dentist who passed the hepatitis virus to 10 patients, two of whom died. The dentist has since stopped practicing, but it is doubtful that his legal problems have stopped.
Most of us use one kind or another of cold sterilant. Although the aldehydes, hypochlorites, phenols, and quats are more effective than alcohol or Zephiran chloride, they should not be considered bacteriocidal, viricidal, fungicidal, or sporicidal as dentists use them.
Chlorine dioxide (Exspor) is the only exception I know of among cold sterilants, and its use in dentistry is limited to plastic or nonmetallic materials because of its corrosive effect on stainless steel. Nevertheless, its toxicity is comparatively low, it is non-irritating to skin and mucous membranes, and it should be an important part of the orthodontist's armamentarium. Yet I find few colleagues who use or even know about Exspor (available from Alcide Corp., Norwalk, CT).
Other techniques, such as glass beads and ultrasonic vibration of cold sterilants, have been proven effective, but only under limited conditions. It seems to me that if orthodontists are going to be serious about instrument sterilization, they will have to rely on the only certain technique available--autoclaving with chemical vapor. (Autoclaving with steam is equally effective, but the steam can corrode metal instruments.)
Implementation of an autoclaving system will not be inexpensive. Large vapor autoclaves cost almost $3,000. More instruments will be needed, and perhaps more staff, but we can hardly ignore the possibility of contamination any longer.
As important as sterilized instruments are in breaking the disease chain, the key to an office hygiene program is cleanliness of hands. A three-minute surgical scrub is not practical for most offices, and our hands could probably not withstand the torture of such constant scrubbing. Still, we must use an antimicrobial soap that kills pathogens. Wearing gloves reduces the skin damage from these effective, but harsh, cleansers.
It probably isn't reasonable to change gloves between patients. Tight-fitting gloves have fewer crevices than skin, fingernails, and nail beds, and are more easily and effectively washed than bare hands.
The main deterrent to wearing gloves is the loss of digital dexterity, but this can be overcome with practice. Latex gloves fit more snugly than vinyl plastic ones. However, they become sticky after one washing, and impossible to work with unless they are dusted with talcum powder. This is why I prefer plastic gloves, but everyone will have to decide based on individual priorities.
We know orthodontic offices can never be as pathogen-free as hospital surgery rooms. They don't need to be. But it is past time to be more diligent about sterilization. We need it, our staff and patients deserve it--and state examining boards or insurance companies may soon demand it.