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1. Cap Movement mm Figure 3 Temperature and Load vs Cap Movement Plot of temperature and load versus displacement cap movement for each manufacturer Temperature measurement with caps pressed during operation The risk of patient burn is greatly increased when the handpiece cap button for changing the bur of any autochuck handpiece is depressed engaged while the handpiece is running This can occur when the button comes in contact with and is depressed by the inside of the patient s cheek ADA investigators performed additional tests to simulate the clinical situation of the handpiece cap being depressed during operation Individual handpieces were mounted in a mechanical test machine Instron Instron Corp and as the handpiece ran at the maximum operating speed and held a standard 557 bur the cap was pressed using a rod attached to the Instron Pilot tests were conducted to determine the distance each cap moved before expelling the bur The surface temperature of the cap was recorded throughout the test The force required to depress the cap and the distance the cap moved were also recorded We operated one handpiece of each type with drive air chip air and chip water on during the test Figure 3 shows the plot of temperature and load versus displacement for each of the handpieces Five of the seven handpieces exhibited a similar trend the Midwest eStylus EA 51LT Micromotor MX Series SIROTorque L and Ti
2. Water Delivery System Delivers sterile procedures Replaces pick up straw in reservoir bottle treats bottled source water S365 Replaces pick up straw in reservoir bottle treats bottled water lt 100 S365M Replaces pick up straw in reservoir bottle treats municipal tap water gt 100 ppm TDS Treats municipal tap water Treats Municipal tap water Centralized system supplies water for 106 dental units Treats Municipal tap water Supplies sterile water to up to 60 dental units Mode of Action Active Ingredient s RE ervo bottles control heads and tubing are Sterilized in a after each patient Continuously elutes 2 6 ppm iodine into treatment water E Steam autoclave Releases antimicrobial silver into treatment water Releases antimicrobial silver into treatment water Continuously elutes 2 6 ppm iodine into treatment water Removes TDS and releases antimicrobial silver into treatment water Filters particulates removes ions and organics and disinfects deionized water with UV Irradiation and silver Physical filtering process and chemical reaction impartinga bacteriostatic e Heats water to 1898
3. Glutaraldehyde spores High level Heat disinfection Destroys all microorganisms but not necessarily high numbers of bacterial spores Liquid immersion EPA registered hospital disinfectant with label claim of tuberculocidal activity e g chlorine containing products quaternary ammonium compounds with alcohol phenolics bromides lodophors EPA registered i chlorine based product Intermediate l Destroys vegetative bacteria most fungi and most viruses does inactivate Mycobacterium tuberculosis var bovis Not necessarily capable of killing bacterial spores level disinfection Low level disinfection Liquid Destroys most vegetative bacteria glutaraldehydes with phenols hydrogen peroxide hydrogen peroxide with peracetic acid peracetic acid Glutaraldehyde glutaraldehydes with phenols hydrogen peroxide hydrogen peroxide with peracetic acid ortho phthalaldehyde Heat sensitive critical or semicritical Not applicable Heat sensitive semicritical Clinical contact Noncritical with surfaces visible blood Blood spills on housekeeping surfaces EPA registered hospital disinfectant with no label claim regarding tuberculocidal activity some fungi and some viruses Does not inactivate Mycobacterium tuberculosis var bovis OSHA also requires label claim of HIV and HBV potency for
4. 1 7 Free run Dry Pre cut Free run Wet Pre cut ese Cuts 1 through 4 Free run Wet Post cut Free run Dry Post cut Handpiece Off Ti Max NL400 Brasseler Average maximum values were calculated from one temperature measurement test on each of three handpieces per product For each manufacturer the yellow highlighted values are the highest average maximum surface temperature readings for the respective pre cutting cutting and post cutting stages Experiments were performed with the ambient room temperature averaging between 23 C to 24 C The highest average maximum surface temperatures occurred at the cap or the head of the handpiece during the pre cutting stage When comparing the information in Table 2 with that in the Appendix we see that the high average maximum surface temperatures in the pre cutting stage occurred when the handpieces were operated with the chip water off After turning the chip water on the surface temperatures continued to rise for a short time before sharply decreasing This further demonstrates the importance of running electric handpieces with the chip water turned on The highest recorded average maximum surface temperature during cutting was on the motors of the following handpieces Micromotor MX Series NuTorque and SIROTorque L The highest average maximum temperature recorded during cutting was at the caps of the following handpieces EA 51LT ELECTROtorque TLC
5. 1 FDA Public Health Notification Patient burns from electric dental handpieces Public Health Notification 1 on Electric Handpieces 12 2007 http www fda gov medicaldevices safety alertsandnotices publichealthnotifications ucmO6 201 8 htm Accessed November 27 2013 2 Electric Handpieces Preventing patient burns ADA Professional Product Review Spring 2009 4 2 16 https www ada org members sections scienceAndResearch O904_ppr pdf Accessed November 27 2013 3 FDA Letter to electric dental handpiece manufacturers regarding reports of overheating and patient burns Notice of safety concern for electric dental handpieces and accessories http www fda gov MedicalDevices ResourcesforYou Industry ucm226986 htm Accessed November 2013 4 American Burn Association Scald injury prevention educator s guide http www ameriburn org Preven ScaldinjuryEducator sGuide pdf Accessed November 27 2013 Dental Electronic Health Records Systems General Considerations Before You Buy Mike Uretz Mike Uretz is a 30 year technology veteran and is the founder and executive director of Dental Software Advisor www dentalsoftwareadvisor com He has consulted with hundreds of practices and multi clinic groups to help them evaluate and select software solutions structure and negotiate contracts and provide management and oversight for their implementations He helped develop national standards and criteria for EHR features and functionali
6. In both cases HPC of the water remained below 10 CFU mL demonstrating the individual effectiveness of both the Stage 5 cartridge and the UV lamp In each of the three laboratory trials the VistaClear system did not maintain counts below 500 CFU mlL for more than 24 hours Besides mechanical filtration the VistaClear system contains a resin within the cartridge to facilitate a bacteriostatic reduction oxidation chemical reaction above pH 8 personal communication with VistaClear As the pH of our source tap water ranged from 6 9 7 8 it is likely that the reduction oxidation reaction never occurred causing the dental unit waterline treatment system to fail This system does not appear to work with water sources lower than DH 8 0 although the manufacturer states an optimum working range of 6 5 8 5 pH for source water During the 12 weeks of operation water treated by Waterclave Water Purifier was less than 10 CFU mL compared to the untreated control which averaged 200 000 CFU mL As long as the temperature Is monitored to ensure the unit is operating between 180 190 C the unit will likely function properly Cost Considerations The ideal time to consider implementing a dental unit waterline treatment device is when you are building a new office or remodeling In general most modern dental units are equipped with a reservoir bottle Alternatively older delivery units can be updated to accommodate various forms of water tre
7. MN 800 972 3543 www dentapure com Sterisil Straw for Municipal Water S365M SIERISILAING Palmer Lake CO 719 622 7200 www sterisil com Sterisil Straw for Distilled Water S365 STERISIL INC Palmer Lake CO 719 622 7200 www sterisil com DentaPure DP365M Dental Unit Water Purification Cartridge MRLB INTERNATIONAL INC Fergus Falls MN 800 972 3543 www dentapure com Sterisil Cartridge SUERISIA ING Palmer Lake CO 719 622 7200 www sterisil com Sterisil System SER SING Palmer Lake CO 719 622 7200 www sterisil com VistaClear 1000 VISTA RESEARCH GROUP LLC Ashland OH Distributed by Pelton amp Crane 800 659 6560 www VistaResearchGroup com Waterclave Water Purifier Model WCJ64 40 VWATERGEAYE WEke Overland Park KS 913 312 5860 www Waterclave com ADA Professional Product Review Dimensions 7 Cost Considerations Control box 12 W x4 AX 3 D CIE 20 W x 29 H x10 D extends to 40 H 3 307 00 for cart one handpiece line excludes handpiece and one syringe line 6 2 HX 3 4 D GAAS IC 0 5 Hx 06025 D 150 00 _ a homer EE ae ERE aE SIP SOE NST EIN ie Se ree m CV SK installation kit for 64 00 TE CV 20 source water gt 150 ppm 160 00 15 5 H x 2 5 D CV 10 source water 76 150 ppm a 130 00 o source water 0 75 ppm 11000 r 4 3 3 3 ES Wy x65 De SS SS Se oS 5 275 00 VistaClear 1000 has been discontinued and is
8. Midwest eStylus and Ti Max NL400 The average maximum surface temperature for three handpieces ELECTROtorque TLC Midwest eStylus and Ti Max NL400 was consistently highest on the cap under all operating conditions However the highest surface temperature recorded for all of the devices was only slightly higher than normal mouth temperature 39 0 C or 102 2 F which presents no significant risk for patient burns Continued on next page amp 2014 Volume 9 Issue 2 ADA Professional Product Review Continued from previous page Temperature and Load vs Cap Movement EA 51LT A dec Teap C ELECTROtorque TLC KaVo Teap C Micromotor MX Series Bien Air Tcap C Midwest eStylus Dentsply Professional Tcap C NuTorque Dental EZ Group StarDental Tcap C SlIROTorque L Sirona Dental Systems Tcap C Ti Max NL400 Brasseler Tcap C 51LT A dec Load N Micromotor MX Series Bien Air Load N So e u Torque Dental EZ Group StarDental Load N ELECTROtorque TLC KaVo Load N co O o Ti Max NL400 Brasseler Load N 5 ROTorque L Sirona Dental Systems Load N idwest eStylus Dentsply Professional Load N ao So 2 2 _ 3 S E pea O 0 00 0 10 0 20 0 30 0 40 0 50 0 60 0 70 0 80 0 90 1 00 1 10 1 20 1 30 1 40 1 50 1 60 1 70 1 80 1 90 2 00
9. Professiona roduct Review A Publication of the Council on Scientific Affa O The ADA Professional Product Review The ADA Professional Product Review is like no other dental product publication online or in print That s because we base our evaluations on comparative testing in the ADA Laboratories We publish the results of our clinical collaborations with dental schools and other groups It s content you can use free from outside influence Read the Review online at ADA org ppr American Dental Association Unbiased scientifically sound research and analysis Product test results from ADA Laboratories Product results from outside collaborations Buyer s checklists Expert panel discussions Technology updates Online supplemental information and resources Dental Therapeutics This publication is not a substitute for the dentist s own judgment about a particular product or service Although the ADA tries to be current information may become outdated In no event shall the American Dental Association or its officers employees agents or consultants be liable for any damages of any kind or nature including without limitation direct indirect special consequential or incidental damages business interruption loss or loss of products arising from or in connection with the use of or reliance upon any information in this publication regardless of whether it has been advised of the
10. across the United States The term total dissolved solids TDS is a measure of mineral salt and metal ions that can deposit on dental waterline tubing and ripen conditions for biofilm establishment Total dissolved solids can range from less than 120 ppm to greater than 350 ppm in surface waters across the United States While municipal water with TDS near 300 ppm may be unlikely it is possible The laboratory formulated tap water represents more challenging conditions than water with low TDS Products intended for use with tap water Sterisil Straw S365m DentaPure DP365M Sterisil Cartridge Sterisil System VistaClear AquaSept system and the Waterclave were supplied with water formulated in the ADA Laboratory to impart a hardness of 160 180 mg L CaCO3 classified as hard by the U S Geological Survey pH 6 5 7 8 and 270 300 mg L total dissolved solids near the top of the U S range for municipal supply water Treatment devices that are intended for use with deionized water DentaPure DP365B and Sterisil Straw S365 were supplied with deionized water of pH 5 5 6 0 This evaluation did not use water formulated to represent private well water Testing All dental unit waterline treatment devices were challenged with a mixture of equal volumes of Pseudomonas aeruginosa and Klebsiella pneumoniae that had been isolated from fresh water environments Laboratory staff members inoculated each water source that
11. s cheek for example it comes in contact with Continued on next page Volume 9 Issue 2 2014 ADA Professional Product Review Continued from previous page the spinning chucking device which results in friction causing both components to heat up instantly ADA laboratory tests were not designed to predict the longevity of the handpiece rather investigators wanted to document the effect of use with and without coolants like water and air on the temperature of well maintained slightly worn handpieces used under normal conditions As noted by the FDA with high and low speed air driven handpieces sluggish handpiece performance will alert the dental practitioner to maintenance Issues such as a dull bur or worn or clogged gears or bearings A poorly maintained electric handpiece does not provide a similar warning that maintenance is needed Instead if an electric handpiece is worn damaged or clogged the electric motor sends increased power to the handpiece head or attachment in order to maintain handpiece performance This increased power can rapidly generate heat at the head of the handpiece attachment Because the heat buildup is so rapid and is efficiently conducted through the metal handpiece a burned patient may be the first indication of handpiece problems that the practitioner receives ADA Laboratory researchers who participated in this evaluation include Dr Spiro Megremis and Henry Lukic References
12. 3 minutes off would be completely used in 2 hours Hence a dentist could use up to 4 reservoir bottles per day However if the flow rate is slowed to 10 mL minute and the intermittent cycle changes to 1 minute on followed by 9 minutes off a single 750 mL reservoir bottle may last an entire day Continued on next page Continued from previous page Table 3 Experimental Operating Parameters Water Treatment Device Flow Rate Filter Capacity L Operating Cycle Testing Interval mL minute AquaSept Heat Sterilizable DS N A 5 minutes on 5 minutes off After each sterilization cycle Independent Water Delivery System DentaPure DP365B Water DS 240 1 minute on 3 minutes off Daily Purification Cartridge Sterisil Straw S365 for 25 240 1 minute on 3 minutes off Daily Distilled Water Sterisil Straw S365M for 25 240 1 minute on 3 minutes off Daily Municipal Water DentaPure DP365M Water 25 240 continuous Daily Purification Cartridge Sterisil Cartridge 25 678 continuous Daily Sterisil System 100 1000 continuous Daily VistaClear 25 567 continuous Daily Waterclave Water Purifier 25 N A continuous Once weekly for 12 weeks According to the manufacturer Calculated with the Cartridge Calculator on www sterisil com AquaSept s operating instructions state that the bottles and tubing must be autoclaved within 4 hours of use Three hours after operation the test bottle control head and tubing were placed in a
13. The Sterisil products on the other hand remove TDS and release silver ions that kill bacteria in the water The TDS level was measured daily as rising TDS levels signal depletion and the need for cartridge replacement Each evaluation remained active until the manufacturer stated maximum amount of water treated was reached or the TDS or iodine threshold was reached Table 2 Ten fold serial dilutions of 50 mL water samples were plated in triplicate using low nutrient Reasoner s 2A R2A agar incubated at room temperature for seven days and enumerated to determine an average heterotrophic plate count HPC as CFU mL Investigators deemed the water treatment device was effective as long as HPC of water exiting the treatment device was less than 500 CFU mL HPC levels exceeding this maximum limit indicated product failure The volume of treated water at which another performance indicator TDS or iodine concentration reached a threshold level is also reported Issue 2 2014 Volume 9 Continued on next page 13 ADA Professional Product Review Continued from previous page Table 4 Summary of Results Water Treatment Average HPC at Capacity TDS lodine at Capacity Device Comment i Overall Performance AquaSept Heat Sterilizable Independent OTU ee ee N A J Water Delivery i DentaPure DP365B Water Purification OCA 2 7h SiS pcmilodi 2 4 JY Cartridge Sterisil Straw S365 for Dist
14. in dentistry and has authored and co authored several peer reviewed scientific papers review articles and research abstracts He was a contributor to the 2003 Centers for Disease Control and Prevention Guidelines for Infection Control in Healthcare Settings He has served as chair of the American National Standards Institute American Dental Association ADA Standards Committee for Dental Products and the Organization for Safety Asepsis and Prevention OSAP He served as a consultant to the ADA Council on Scientific Affairs and is a peer reviewer for the Journal of the American Dental Association ach year at the ADA s annual dental meeting the ADA Professional Product Review hosts a CE program called the Product Forum which allows dentists to learn about product selection and evaluations In 2012 the Product Forum focused on infection control products including surface disinfectants Two infection control experts Dr Shannon Mills and Dr John Tullner were on hand to answer participants questions In this issue the ADA Professional Product Review s editor Dr David Sarrett poses questions to Drs Mills and Tullner about the use of surface disinfectants in the dental office Dr David Sarrett How effective are surface disinfectants and what do dentists need to know about their proper use Dr Shannon Mills When used as directed disinfectants should make it unlikely for disease transmission to occur because of co
15. items are open to air they will eventually become contaminated Thus the longer a sterile item is exposed to air the greater the number of microorganisms that will settle on it Because flash sterilized items are intended for immediate use and must remain sterile they would not be bagged after sterilization The CDC s Guidelines for Infection Control in Dental Health Care Settings 2003 also state Preparation and Packaging In another section of the processing area cleaned instruments and other dental supplies should be inspected assembled into sets or trays and wrapped packaged or placed into container systems for sterilization Hinged instruments should be processed open and unlocked An internal chemical indicator should be placed in every package In addition an external chemical indicator e g chemical indicator tape should be used when the internal indicator cannot be seen from outside the package For unwrapped loads at a minimum an internal chemical indicator should be placed in the tray or cassette with items to be sterilized see Sterilization of Unwrapped Instruments Dental practices should refer to the manufacturer s instructions regarding use and correct placement of chemical indicators see Sterilization Monitoring Critical and semi critical instruments that will be stored should be wrapped or placed in containers e g cassettes or organizing trays designed to maintain sterility duri
16. leave surface cleaners on It s simple stuff but overlooked People need to read the instructions A dentist visiting the ADA Professional Product Review s 2012 Product Forum germicide has been tested against These usually include both lipid and non lipid viruses and representative fungi Any disinfectant that is tuberculocidal will generally kill other viruses bacteria or fungi but will not inactivate bacterial spores Low level disinfectants do not have to be tuberculocidal and can be used on housekeeping surfaces that are not contacted during procedures In addition to tuberculocidal activity high level disinfectants can inactivate bacterial spores with sufficient contact time They are not considered surface disinfectants and are used for high level immersion disinfection or sterilization of instruments and other items that contact or penetrate skin or mucous membranes that cannot withstand sterilization with heat DS Can high level disinfectants such as those that contain glutaraldehyde be used for surface disinfection JT No Never use high level disinfectant chemicals for surface disinfection Improper use of these products is in violation of Federal Law See the label and package insert DS Why should dentists be concerned about whether or not their disinfectant kills TB JT We should be concerned because Mycobacterium tuberculosis var bovis is a very resistant organism that is hard to kill and
17. lodine test strips sold Separately product packaging and information the manufacturer submitted on the ADA Laboratory s technical product table form Reverse x s N OSMOSIS v x 2 filters F chemical shock si accessories E et 5 gt lt qm ro N Continued on next page Gy ADA Professional Product Review Continued from previous page Dental Unit Water Test System Design The ADA Laboratory staff developed test equipment to evaluate the DentaPure DP365M DentaPure DP365B MRLB International Inc Fergus Falls Minn Sterisil Straw S365m for municipal water Sterisil Straw S365 for distilled water Sterisil Cartridge Sterisil System Sterisil Inc Palmer Lake Colo and VistaClear Vista Research Group LLC Ashland Ohio Table 1 The test equipment was equipped with drive air pressure pressure gauges and regulators to supply air and water as specified by the manufacturer flow meters and solenoid valves to control flow rate through dental unit tubing and reservoir bottles to simulate a delivery system using parts commonly available from dental and industrial supply companies The Waterclave Water Purifier Waterclave LLC Overland Park Kan received water using a peristaltic pump and flow meter And as its name states the AquaSept Heat Sterilizable Independent Water Delivery System is an independent water delivery system Water Source Chemical properties of municipal water vary widely
18. possibility of such damages Reference to any product is not and shall not be deemed an endorsement of that product
19. re colonization when only disinfecting methods are used for control Disinfecting dental unit waterlines can be challenging because the tubing is not easily accessible Measures to control build up of biofilm in the tubing typically focus on the treatment of incoming water or the introduction of chemical disinfectants via a reservoir bottle before delivery to the patient Treatment of incoming water from the main municipal supply at the operatory level can be accomplished by water purification ozone treatment ultraviolet radiation and or filtration methods which can be expensive but generally require less frequent maintenance than the intermittent or continuous use of chemical disinfectants which are relatively inexpensive and seemingly straightforward While the cost of chemical treatments can be just pennies per use these products must be delivered according to a set schedule to be effective Maintenance solutions are placed in the reservoir bottle each time it is filled followed by the delivery of shock solutions on a weekly or monthly basis according to the manufacturer s instructions While the initial investment for devices that treat incoming water is greater at the outset Table 1 less expensive chemical disinfectants present more opportunities for human error such as neglecting to apply a chemical treatment according to schedule See Cost Considerations on page 10 for more information about cost The ADA Lab
20. replaced by mo multi chair VistaClear 2000 Model So WO Sab which retails for y 5 999 00 t The mode of operation is identical for both models Ter WE 20 Fx 27 D 10 995 00 The manufacturer s suggested retail price is as of February 2014 Actual price may vary Price includes cart one handpiece line and one syringe line Must purchase additional handpiece and syringe lines to accommodate procedure load between autoclave cycles Cost of each additional handpiece and syringe line is 695 00 The in line cartridge fits in the junction floor box of the dental unit while the valved cartridge is cabinet mounted Appropriate model is based on Total Dissolved Solids TDS measurement of your office tap water using a TDS 3 Handheld meter Sterisil Inc The CV 20 Model was recommended by Sterisil based on TDS level of source water used in this evaluation 300 ppm Contact Sterisil to select the right cartridge based on the TDS level of your water Continued on next page Continued from previous page Table 2 Product Features Waterclave Water Purifier Sterisil System Sterisil DentaPure Sterisil Straw for DP365M_ Cartridge Purification Cartridge Sterisil Straw for Distilled Municipal Water Water DentaPure DP365B i Purification Cartridge Water Treatment Device AquaSept Heat Sterilizable VistaClear Intended Use water for dental Independent
21. sterilization pouch and sterilized in a pre vacuum chamber steam sterilizer at 132 C for 15 minutes Following sterilization and cooling the test and control bottles were filled with sterile deionized water Treatment devices intended for use within reservoir bottles that is DentaPure DP365B Sterisil Straws S365 and S365M were operated intermittently for 1 minute on followed by 3 minutes off to mimic dental unit water delivery during patient treatment The investigators operated the DentaPure DP365M Sterisil Cartridge Sterisil System VistaClear and Waterclave continuously They operated the AquaSept system for 5 minutes on followed by 5 minutes off until it had expelled 8 oz 236 mL of water The investigators tested water samples collected from the treated water supply at regular intervals Table 3 AquaSept operated for 103 use sterilization cycles and was tested after each cycle Investigators tested Waterclave weekly over 12 weeks as its operation is not limited by volume Treated water samples from the remaining devices were tested daily and the volume of water treated by each device was recorded throughout the evaluation As indicated in Table 2 the DentaPure DP365B and DentaPure DP365M Purification Cartridges release iodine to disinfect the water For these products the investigators routinely measured iodine levels to determine when the device was nearly depleted of iodine and would require cartridge replacement
22. throughout the evaluation including after filtering a total of 645 L water Sterisil states an ideal capacity of 100 L water or 5 months of clinical use for the Sterisil Cartridge CV 20 Filter However under the operating conditions and water hardness levels employed in this evaluation it was estimated that the cartridge could effectively treat approximately 67 L of water Experimentally a total of 61 L water was effectively treated before the TDS reached a measurement greater than 10 ppm After treating 66 L of water the HPC jumped to greater than 500 CFU mL and the cartridge emitted a fish like odor which signaled total depletion of the deionizing material The additional 5 L of effectively treated water corresponds to about one week of use allowing enough time to replace the cartridge once the TDS measurement rises above 10 ppm signaling the device is no longer effective Hence the Sterisil Cartridge and corresponding manufacturer recommendations were deemed very accurate As such users may have better Continued on next page G5 2014 Volume 9 Issue 2 ADA Professional Product Review Continued from previous page results if they change the cartridge when the TDS reading rises above 10 ppm rather than waiting until a rise in microbial counts or an odor occurs Following the manufacturer s recommendations and its online Cartridge Calculator will result in the most effective use of this product Based on the Cartridge C
23. use of low level disinfectant for use on clinical contact surfaces e g quaternary ammonium compounds some phenolics some iodophors Noncritical without visible blood Clinical contact surfaces Housekeeping surfaces The U S Environmental Protection Agency EPA and the U S Food and Drug Administration FDA regulate chemical germicides used in health care settings The FDA regulates chemical sterilants used on critical and semicritical medical devices and the EPA regulates gaseous sterilants and liquid chemical disinfectants used on noncritical surfaces FDA also regulates medical devices including sterilizers Inactivation of the more resistant Mycobacterium tuberculosis var bovis is used as a benchmark to measure germicidal potency CDC Guidelines for infection control in dental health care settings 2003 MMWR2003 52 No RR 1 7 1 66 Continued on next page Continued from previous page blood or saliva an EPA registered intermediate level disinfectant should be used When there is no visible contamination bioburden a low level disinfectant should suffice It s always important to remember that proper pre cleaning of all environmental surfaces or equipment is of major importance prior to disinfection DS What s the difference between one and two step surface disinfectants SM A one step product is effective as both a cleaner and disinfectant Some types of germicides are
24. Document vendor commitments and promises from a legal standpoint by making certain that these commitments and promises are fully incorporated in the contract since if they are not included in the contract they will generally be unenforceable Soliciting RFPs doesn t cost anything but time Because RFPs require vendors to prepare customized proposals the process gives you a good idea of which vendors are serious about working with you and which can best accommodate your needs The RFP can cover several areas and at a minimum should include A comparison of vendor software features and functionality prioritized and based on what is important to your practice The prioritization will also help you develop clinical scenarios for vendor demonstrations A vendor business profile including the organization s structure financial information software product history reference sites etc The underlying technology that the software is built on along with other technical and IT focused considerations A description of a vendor s implementation and training plans and processes A detailed proposal of cost items broken down so that you can accurately compare the various proposals you are reviewing including post purchase support and maintenance Make certain that any commitments and promises in the RFP on which you are relying are included in the purchase agreement In one of my workshops a dentist said I went
25. Each of the tested handpieces followed the general trend of the heads and caps heating up with time when they are run without the chip water By contrast after the chip water is turned on the surface temperature of the handpiece heads and caps decreases Furthermore the surface temperatures measured at the motor steadily rise when the chip water is off and start to level off when the chip water is turned on These trends demonstrate the importance of having the chip water on whenever the handpiece is running Table 2 shows the average maximum surface temperatures for the different handpiece brands One temperature measurement test was performed on three handpieces for each manufacturer For each manufacturer investigators then calculated the average maximum values for each of the thermocouples during the different stages of handpiece operation During the experiments the ambient room temperature averaged between 23 C and 24 C Continued on next page Continued from previous page Table 2 Average maximum surface temperature readings maximum standard deviation in degrees Celsius EA SILT ELECTROtorque MicromotorMX Midwest eStylus NuTorque SIROTorque L kdi TLC Dentsply DentalEZ Star ieee KaVo Professional Dental stents Ti T2 T3 T1 T2 T3 Ti Ti T2 T3 Head Cap Motor Head Cap Motor Hea Motor Head Cap Motor 24 9 25 2 25 3 26 hi i i 24 9 25 3 24 8 Handpiece ff 0 8 1 4 i
26. F OO with oee Recommended Operating Air Pressure Recommended Flow Rate 100 mL min 2 0 76 L min 0 20 gallons gt min Capacity volume of water Varies depends Tom Doan water 1 000 L per yea Purifies 15 gallons per hour Indicator Threshold lodine must be gt 0 5 ppm 2 lodine must be gt 0 5 ppm TDS must remain below 10 2 TDS must remain below 10 Recommended Shock Treatment Built in shock treatment Built in shock treatment Built in shock treatment Citrisil by Sterisil Inc VistaTab for initial shock Sterilex Ultra Liquid by Sterilex Corp Power Requirements Must be installed near an electrical outlet Must install near electrical source having appropriate voltage 208 or 240 V Audible Visible Alarm Ongoing Maintenance Costs Multiple cartridges per year Psy Oe for filter replacement COST VistaClean cleaning solution MUOGEUEL JA i Service NEY Ele E Replacement Parts and Accessories 16 oz bottles or adapters various size sterilized water bottles Sterilization cassette Systems are available that will treat 3 000 7 000 and 10 000 liters of water annually This information was collected from the manufacturers directions for use lodine test strips sold Separately
27. Max NL400 all showed an initial range of cap movement but no significant change in temperature However as the caps were depressed more a critical region was observed where the cap temperature rose dramatically A slightly different trend was observed for the ELECTROtorque TLC green curves and the NuTorque black curves handpieces These devices exhibited an increase in cap temperature in a region where cap movement takes place with very little resistance followed by the previously described region where additional small movements resulted in dangerously high cap temperatures Continued on next page Continued from previous page Table 3 Critical Region values for temperature measurement with caps depressed during operation Handpiece Temp Starts to Increase a m m m m m m m m m me m m m m m m me m m m me a m m m m m m e m m m m m me m m m m m m me m me m m m me m m e m me m m m m ma m m m m ma me m m m me me me m m m m e m m m m a m m m m m m m m m m m m m m REREN Oo Bur Expelled Max Temp C am mmm nn m e m m m m m m m m m m m m m m m 2 Data is for tests performed on one handpiece from each of the seven manufacturers The Critical region is defined from the cap push button movement at which the temperature starts to rise up until the point at which the bur is expelled Table 3 provides data on the critical region for each handpiece or the region where the cap temperature of the han
28. Table 4 Based on this information the maximum temperature recorded for five of the seven handpieces tested could burn a patient should contact occur for as little as one second or as long as 5 minutes Furthermore it should be noted that during testing Table 4 Time and temperature relationship to severe burns 1 second 5 seconds Temperature the burs were held such that when they were expelled gravity caused them to drop from the handpieces However this may not occur in a clinical situation it is possible that the handpiece may not be positioned such that the bur drops out and the temperature could continue to rise Bottom Line The results of the temperature measurement tests performed in this study point to the importance of operating the electric handpieces with the chip water turned on When we operated the handpieces according to the manufacturer s instructions the temperatures of the handpieces did not exceed mouth temperature while cutting through ceramic blocks at room temperature During cutting we recorded the highest average maximum handpiece temperatures on either the cap or the motor Additional testing showed that pressing down on the handpiece cap push button while it is operating can result in dangerously high cap temperatures A section of the handpiece chucking device mostly made of metal components spins at about 200 000 rpm When the cap is continuously depressed by touching a patient
29. U mL limit was marginally exceeded with an average of 1060 CFU mL near the product s capacity The untreated control line averaged 302 000 CFU mL Sterisil recommends use of the Straw S365M with good quality tap water As municipal water will generally have lower microbial counts than those used in the evaluation regular monitoring of dental unit water quality can confirm the water treatment system is working effectively Sterisil will test a customer s dental office water and advise on the best device for that dental office s specific water chemistry The DentaPure DP365M Water Purification Cartridge installed in or near junction box after the water pressure regulator was highly effective Figure 1 Tear in AquaSept tubing after 103 use sterilization cycles Note The manufacturer recommends 100 use sterilization cycles corresponding to about 5 months of use throughout the evaluation with an average HPC less than 10 CFU mL for treated water and 46 000 CFU mL for the control line In addition despite the stated capacity of 240 L for the water purification cartridge 645 L water was effectively treated before the filter clogged Also DentaPure instructs dentists to monitor available iodine levels as part of the water monitoring regimen and to change the purification cartridge when the iodine level reaches 0 5 ppm Through the use of iodine test strips investigators determined that the iodine level never dropped below 1 0 ppm
30. Volume 9 Issue 2 2014 ADA Professiona Product Review A Publication of the Council on Scientific Affairs Unbiased Letter from the Editor David C Sarrett DMD MS Scientifically Sound All good publications do routine evaluations to determine how to best serve their readers and the ADA Professional Product Review is no exception Feedback comes to me from many sources fellow faculty and deans dental students and others And we routinely survey groups of ADA members to get input about topics the newsletter should pursue Based on that feedback we are expanding our content to provide a variety of information on dental equipment materials occupational safety and health issues and other areas that affect your daily practice Clinically Relevant User Friendly For this issue we interviewed Dr Shannon Mills and Dr John Tullner for the article Surface Disinfectants What dentists and their staff need to know Disinfectant products have been around for decades but you may be surprised to hear what they have to say about contact time and efficacy In a new feature Mailbox we ll be answering some of the many questions that ADA members pose to the ADA s Division of Science such as Must bag all instruments What if use them as soon as they have been autoclaved Can bag instruments after sterilization Can wear a short sleeve lab jacket when it s hot The ADA Laboratory also did two evaluati
31. alculator and our laboratory tests it appears that the lower the TDS of the dental office water the longer the working life for this device The Sterisil System maintained effectiveness throughout the duration of the evaluation with HPC less than 10 CFU mL while the control line reached 46 000 CFU mL The Sterisil System treats municipal water by reducing TDS in order to supply an entire office with water having less than 10 ppm TDS More specifically the Stage 3 reverse osmosis filter removes 85 of TDS and is followed by another deionizing filter to reduce the TDS to a negligible level Finally the water travels through an ultraviolet UV lamp and a silver releasing Stage 5 cartridge for disinfection The device monitors the deionizing filter and the reverse osmosis filter performance which can be easily read on the display According to the manufacturer the product will effectively treat about 1 000 L water According to their findings the investigators determined that the device had effectively treated 1 277 L water the final water sample was measured to have 4 ppm TDS and all filters appeared to be functioning without the need for replacement To investigate and confirm continued disinfection we unplugged the UV lamp to verify that the silver releasing Stage 5 antimicrobial cartridge was effectively functioning Similarly the Stage 5 cartridge was exchanged for a blank cartridge to verify that the UV lamp was still functioning
32. also detergents or contain surfactants that help remove organic soil Some products particularly those with high alcohol content can actually impede the removal of organic soil and require pre cleaning with a detergent to be fully effective These types of products are often referred to as two step disinfectants Using a one step disinfectant does not mean that the cleaning step can be skipped when surfaces are contaminated DS Do surfaces need to be pre cleaned before you use a surface disinfectant JT Absolutely learned early on from Dr Jim Crawford a pioneering and pivotal figure in dental infection control and others that pre cleaning is a critical part of the disinfection process All visible bioburden should be removed for disinfectants to properly do their job DS What about formulations You mentioned that manufacturers may keep brand names but change their formulas Do dentists need to be concerned about that Table 2 Decreasing order of resistance of microorganisms to germicidal chemicals ORGANISM Bacterial spores Geobacillus stearothermophilus PROCESSING LEVEL REQUIRED FOR STERILIZATION FDA sterilant high level disinfectant CDC sterilant high level disinfectant JT In some cases manufacturers market two products with similar names but they may have a different chemical formulation disinfectant An example is Clorox Disinfecting Wipes an alcohol dual quaternary ammonium product and Clorox Blea
33. ar did not maintain HPCs below 500 CFU mL for more than 24 hours During the 12 weeks of operation water treated by Waterclave Water Purifier had HPCs of less than 10 CFU mL compared to the untreated control which averaged 200 000 CFU mL The Bottom Line Dentists and their staff members should monitor microbiological quality of dental unit water regularly Under the experimental conditions employed by the ADA Laboratory all of the dental unit waterline treatment devices effectively treated 500 CFU mL source water except for the VistaClear and Sterisil Straw S365M As municipal water will generally have lower microbial counts and varying chemistry than the source water used in the evaluation it is important to assess the quality of dental office water i e microbial counts hardness total dissolved solids pH etc before purchasing and installing a dental unit waterline treatment system ADA Laboratory researchers who participated in this evaluation include Stephen E Gruninger Kristy L Vogt and Rashad Vinh References 1 U S Environmental Protection Agency Safe Drinking Water Act http water epa gov lawsregs rulesregs sdwa Accessed October 7 2013 2 Fulford MR Walker JT Martin MV and Marsh PD Measuring Bacterial Contamination in water units Br Dent J 2004 196 157 59 3 Mills SE The dental unit waterline controversy defusing the myths defining the solutions JADA 2000 131 10 1427 41 4 Panagakos FS Lassit
34. as such is considered the benchmark organism for intermediate level disinfectants If you refer to the CDC Guidelines for Infection Control in Dental Health Care Settings 2003 you ll see that intermediate level disinfectants kill all of the pathogens we are most concerned about in dentistry but they do not kill spore formers DS What s the first step in the proper use of surface disinfectants JT feel the first step is reading the label instructions carefully Directions for proper use dilution factors if not ready to use organism kill claims safety information contact times cleaning ability and compatibility with materials and surfaces are some examples of characteristics that can vary significantly between disinfectant products SM Another important first step is seeing noting the kill time for Mycobacterium tuberculosis for intermediate level hospital disinfectants which is sometimes highlighted in the manufacturer s promotional materials but the user may not realize that the overall contact time is longer Adding alcohol to a product can reduce TB kill times but not affect the kill time for other bacteria viruses and fungi Read the whole label and the directions for use before buying or using a product Keep in mind also that M tuberculosis is included in label claims because it represents an organism that is resistant to many kinds of disinfectants not because it represents a significant ha
35. ated water has no more than 500 CFU mL bacteria which reflects the EPA s maximum safe level of heterotrophic bacteria in drinking water gt The American Dental Association s Council on Scientific Affairs Statement on Dental Unit Waterlines updated in 2012 notes that dental unit waterlines must be maintained regularly to deliver water of an optimal microbiologic quality Thus every dental office infection control plan should include a process for maintaining dental unit water quality Dental unit waterlines are considered an ideal substrate for biofilms which thrive in an aqueous environment characterized by frequent periods of stagnation The small volume of water that passes through tubing with a relatively large surface area interior tubing diameter is typically 1 5 2 mm creates a large volume to surface area ratio where decreased laminar flow at the tubing wall increases the potential for biofilm formation If left unmanaged organisms can proliferate to several hundred times their original concentration Minerals from tap water deposit onto the tubing wall and become attachment sites for bacteria Dead bacteria and other organic matter reinforce bacterial growth on the interior tubing wall forming a dense protective matrix that hinders biofilm removal The matrix encourages biofilm maturation and thickening narrows the tubing channel restricts water flow and provides the foundation for rapid microbial
36. atment For example an existing dental unit can be retrofitted with a reservoir bottle and toggle switch to supply treated water from the main water supply and disinfectant solutions via the reservoir bottle Such an approach is estimated at about 500 00 per unit An additional cost to aretrofitted system is the need to shock the existing waterlines with a chemical cleaner until appropriate monitoring procedures indicate the accumulated microbes reach an acceptable level The approximate annual cost of chemical waterline treatment per dental unit fitted with a 0 7 L reservoir bottle ranges from 87 75 to 277 00 depending on the product In addition if a new building or remodel is not in the foreseeable future the cost to plumb or modify a dental office s current plumbing scheme to accommodate a specific dental unit waterline treatment device should be considered Continued on next page Continued from previous page For some of the devices evaluated here power consumption costs are another consideration For example the Waterclave Water Purifier requires 4 kWh electricity per hour Assuming a cost of 0 056 per kWh the annual cost to supply power to the Waterclave is approximately 38 00 annually 3 19 per month Alternatively the annual cost to supply power to the Sterisil System is about 63 00 5 00 per month Another point for consideration is that some of the devices such as the DentaPure DP365B Water Purification Cart
37. ch Germicidal Wipes a sodium hypochlorite bleach product Both are EPA registered disinfectants but they have different chemical formulations believe that many people think of Clorox as bleach so this can be confusing if dentists and their staff do not carefully read the label DS How long should you leave a surface disinfectant on JT Times vary for each product generally between one and 10 minutes can t stress enough how important it is to read the product label for proper use Also make sure you use enough disinfectant so that it does not evaporate in less than the required contact time DS What other considerations should you watch out for JT Check the shelf life and reuse life of the product as well as the expiration date Also make sure if the product needs to be diluted and follow the manufacturer s instructions Do not mix additional products or add soap to a disinfectant That practice can inactivate the chemical disinfectant and can also be dangerous reverence Bacillus atrophaeus Mycobacteria Myobacterium tuberculosis Nonlipid or small viruses Polio virus Coxsackie virus Rhinovirus Fungi Aspergillus Candida Vegetative bacteria Staphylococcus species Pseudomonas species Salmonella species Lipid or medium sized viruses Human immunodeficiency virus Herpes simplex virus Hepatitis B and hepatitis C Coronavirus problems In Block SS ed Disinfection sterilization an eee ee
38. ctice s short term and long term needs A Both of these are important to consider For example some short term needs might be the ability to consolidate all of the patient s clinical information in one place make the clinical workflow more efficient and productive or send automated follow up notifications Long term needs might be offering patients a web portal to help support better communication or looking at the ability to interface with a new imaging system Continued on next page Continued from previous page that will be purchased down the road Q How can the selection team best evaluate multiple features and functionality among the various parts of a potential EHR system A Having specific features and functionality is one thing but making sure they are easy to use intuitive and navigable is another This is the subjective part of all this and where a practice can risk falling short Watch out for vendor account reps who try to control the demonstrations showing what they want to show you not necessarily answering your questions and overall being in control of the process So instead of spending time seeing things that might not be critical to your decision making wouldn t it make more sense to take charge and get what you need out of the product demonstration instead of your account rep s view of what they think you need With dental electronic health records and associated clinical software the first st
39. dpiece starts to rise with increasing cap movement For each individual handpiece tested the table gives the displacement and load corresponding to a rise in cap temperature This indicates the beginning of the critical region The table indicates the maximum distance the cap push button was moved i e the point at which the bur is expelled and the maximum load associated with its resistance to depression The maximum temperature recorded during the test is also provided The data in Table 3 demonstrate that the total cap movement to expel the bur is less than 2 mm for all of the handpieces Furthermore the distance the caps could be moved before the temperature of the caps began to rise is in the range of 0 81 mm ELECTROtorque TLC to 1 67 mm EA 51LT The measured loads at these displacements were 7 6 N and 3 4 N respectively However the load measured to push the cap down to the point of expelling the bur ranged from 8 9 N about 2 Ibs for the EA 51LT to 25 7 N almost 6 Ibs for the Ti Max NL400 At the point the bur is expelled moving parts are touching and the temperature of the handpiece caps rises dramatically from 42 C for the NuTorque to 132 C for the ELECTROtorque TLC As noted by the American Burn Association third degree burns can occur in as little as one second when tissue Is exposed to temperatures of at least 68 C a five minute exposure can cause third degree burns at temperatures of at least 48 C
40. e eee ee ee ee ee ee ee eee Lee eS eS eS eS eS ee Se Se ee aos EPA hospital disinfectant with tuberculocidal laim CDC interm level disinfectant em E a a i n i Continued on next page 2014 Volume 9 Issue 2 ADA Professional Product Review Continued from previous page SM To avoid corrosion discoloration or other damage to surfaces on dental equipment including chairs units and accessories which may be caused by disinfectants contact the equipment manufacturer for its recommendations You may also find this information in your user manual Always use the products as directed especially in regards to contact time and personal protective equipment DS Anything else you d like to add JT It s not important to get brand names it s important to know the concepts and how to choose a product And be sure to have all users wear appropriate personal protective equipment such as gloves eye protection and appropriate clothing If you have disinfectant equipment compatibility questions it s best to contact the manufacturer for advice This can avoid costly damage Have a blood spill kit available for pre cleaning prior to disinfection of large spills SM While disinfectants are important adjuncts to infection control practice they can damage surfaces and may pose risk for personnel To reduce use of disinfectants consider the use of single use disposable barriers where practical You can find
41. ead C TZO C Free run Dry a Pre cut Fen Cuts 1 through 4 E wa E is pect as T3 Motor C 240 er T4 Ambient C Handpiece Free run Dry ee oe Time sec Figure 2 Sample temperature versus time curve for an electric handpiece as tested in this study with the handpiece control unit set at the maximum operating speed approx 200 000 rpm for all handpieces and with both the drive and chip air on but the chip water off After approximately 60 seconds the chip waterw as turned on and ran the handpiece for approximately another 60 seconds We then used 557 burs and a 150 g weight to apply a cutting load and cut through a 38 mm long Macor ceramic block with the handpiece The procedure was repeated three times making a total of four parallel cuts in the Macor block After approximately 60 seconds the chip water was turned on and the handpiece ran for about another 60 seconds The handpiece was then run for approximately 30 seconds with the drive air and chip water and air turned on followed by running the handpiece an additional 90 seconds with the chip water off Finally the handpiece was turned off including all air and water and the handpiece temperature was recorded for another 120 seconds Figure 2 shows a sample temperature versus time curve for the electric handpieces See Appendix A for representative temperature vs time curves for the individual handpieces
42. ectants kill Mycobacterium tuberculosis var bovis a very resistant organism but not a human pathogen as well as but not limited to fungi such as candida Rhinovirus Coxsackie and Polio viruses bacteria such as staphylococcus pseudomonas and salmonella species and viruses such as HIV HSV and Hepatitis B and C Low level hospital grade disinfectants have a more limited spectrum but are also effective against staphylococcus pseudomonas and salmonella species as well as HIV HSV and Hepatitis B and C highly recommend that dentists refer to the chart on page 64 in Appendix A of the CDC Guidelines for Infection Control in Dental Health Care Settings 2003 SM To know which organisms are killed you again have to read the label Intermediate level hospital disinfectants are often used on surfaces that are routinely touched during patient care To be considered an intermediate hospital disinfectant the product must be able to kill certain specific bacterial species including Mycobacterium tuberculosis This organism is considered the benchmark for this class of disinfectants because it represents a type of bacterium that is resistant to many kinds of chemical disinfectants not because it is transmitted from environmental surfaces The label specifically lists viruses and other organisms that the Continued on next page Continued from previous page One of the most common questions get asked is How long should I
43. egistration has been approved for use as a disinfectant in the United States and is safe when used according to the manufacturer s directions for use These directions may include use of personal protective equipment or proper ventilation of spaces where the disinfectant is used Consult the product s Safety Data Sheet for complete information JT First one needs to decide on the purpose the product is to be used for If the product is to be used for contaminated clinic housekeeping surfaces such as sinks walls or floors an EPA registered hospital low level detergent disinfectant is recommended or in some cases where there Is minimal contamination a good detergent with water would suffice In the case of high touch clinical contact environmental surfaces in the dental clinic if the surface is visibly contaminated with Table 1 Methods for Sterilizing and Disinfecting Patient Care Items and Environmental Surfaces APPLICATION PROCESS DEFINITION W o LOD EXAMIPLE Paent Care items Environmental Surfaces Sterilization Steam dry heat Heat tolerant critical 2 unsaturated chemical vapor and semicritical Heat l Heat tolerant or heat 2 Ethylene oxide gas plasma bs Se Destroys all Low Acie sensitive critical and sterilization Pay microorganisms semicritical includin bacterial m a mR BO EEEREET EER EE EE EE OEE EOE OE EEE EE EE EEE EEE EE SEE CEE EEE CRE EEE EEE REET EERE CEE EEE EEO J
44. einvested a small amount of their revenues toward research and development or support And what if the vendor you are considering hasn t had a major update or release for the past two years Profiling a vendor s organization and sales history is Something that many buyers don t consider When checking references it s helpful to have a set of questions you can use to compare each vendor Besides finding out how satisfied their customers are with the use and operation of the system find out their experiences including negative experiences or problems regarding the vendor s implementation support and communication Q What could dentists do if they feel that they don t have adequate knowledge and experience to conduct some aspects of the pre purchase analysis A Often a provider or administrator doesn t have the technical skills to properly evaluate the technology and there are some important technical areas that need to be evaluated while comparing dental EHR vendors For example in one case the EHR system was built on proprietary older technology If we had selected that solution the practice would have ultimately been limited by the technology because the vendor was the only one that could make changes or updates And since it was older technology we did not have the scalability to meet the growing needs of the practice over the next few years The bottom line was that even though the first solution was a bit more
45. ep is to develop a number of clinical scenarios visits that represent what you would normally see on a daily basis You can embellish these with additional issues and problems that may come up during the visit It s very helpful to see how a vendor and their software deal with these types of scenarios Sometimes it is difficult to keep to the script especially when an account rep has an agenda but remember that you are trying to get answers to what you need so stay with the program Q What about using some clinical scenarios in vendor demos A Some vendors would prefer to lead the product demonstration and show the practice what the vendor wants to show They might stay away from the software s weaknesses or functionality that is missing By providing the vendor with clinical scenarios that reflect actual patient exams and workflows the practice owner can better evaluate if the software supports the office s daily needs Q What should buyers look for in a vendor A Ask potential vendors about their experience with individual practices group practices and specialty practices the size of support and customer service staff and their R amp D staff Make sure that they have actually sold and supported EHRs to practices that are similar to your practice For example if you have a small practice how would you feel if the vendor you were evaluating had only 10 sales in the small practice market or vice versa What if they only r
46. er T and Kumar E Dental unit waterlines review and product evaluation J N J Dent Assoc 72 2 20 38 5 ADA Council on Scientific Affairs Statement on dental unit waterlines 201 2 http www ada org 1856 aspx Accessed October 7 2013 6 U S Centers for Disease Control and Prevention Guidelines for infection control in dental health care settings 2003 In U S Department of Health amp Human Services editor Atlanta GA Epidemiology Programs Office 2003 p 29 7 Van der Leeden F Troise FL Todd DK The Water Encyclopedia 2nd ed Chelsea Michigan Lewis Publishers 1990 p 808 8 Standard Methods for the Examination of Water and Wastewater American Public Health Association 1999 2014 Volume 9 Issue 2 ADA Professional Product Review A Laboratory Evaluation of Electric Handpiece Temperature and the Associated Risk of Burns n December 2007 the U S Food and Drug Administration FDA issued a Public Health Notification report that warned healthcare professionals about serious patient injuries including third degree burns associated with the use of poorly maintained electric dental handpieces during dental procedures The ADA Professional Product Review Volume 4 Issue 2 summarized these concerns and presented several FDA recommended strategies to prevent such injury Despite increased awareness of this safety issue the FDA continues to receive reports regarding injuries and burns associated with elec
47. er consideration Q What should a dentist consider when selecting a vendor or vendors for digital technologies A There are several factors that come into play including The vendor s organizational profile and experience with your specific market The usability and navigation of the software Technical considerations and aspects of the software The vendor s processes for implementation and training Competitive pricing including training support and maintenance and upgrades Contract terms including warranties indemnities and limitations of liability Q Who should be involved in the EHR selection process A Putting together a selection team that represents various skill sets and functional areas is important no matter what size practice Practices that create a selection team are the most successful with their EHR software evaluation and selection Whether you have a staff of three or many more staff members with different skill sets will use different aspects of your EHR software Have the person that s responsible for billing take part in the evaluation of billing and claims processing functionality Otherwise you run the risk of missing some of the nuances of the systems you re evaluating An internal selection team also helps the office make the transition to electronic health records or next generation practice software a bit easier The learning curve can be steep and everyone has to be on boa
48. erations were negatively affected during a poor implementation For example a vendor may say that software implementation will take three months but six months later the system still isn t working correctly How do you prevent your practice from being a case study in a bad implementation First make sure that your contract reflects guarantees by the vendor on how the project will move forward You can review how a vendor plans and executes implementation and training prior to selecting the vendor How detailed an implementation and training project plan is can be an indication of the potential for success A potential vendor should provide examples of project plans and implementation methodologies There are no guarantees that when you do get into the implementation the vendor will adhere to the plan that s what the contract is for But at least if they can show you that they have detailed project planning and good implementation strategies then you know that they understand how to run a successful project And that s a good start To help assure getting a good implementation after a practice has purchased the products it is important to make sure there is a solid project plan developed plan for necessary resources and time have regular status meetings to improve accountability and be involved in the execution of the plan Q What about price value and total cost of ownership in this process A wish that all vendors
49. expensive they didn t want to get stuck with older proprietary non scalable technology It could be helpful in the pre purchase process to engage a technical expert to help evaluate the underlying technology on which the system is built so you don t get stuck with a limited non scalable system Q How might dentists systematically approach the selection of digital products for their EHR system A There are several things they can do Determine which clinical features are most important to the practice the deal breakers Put together a Request for Proposal RFP Shorten the vendor list by analyzing RFP responses 7 Conduct practice controlled organized vendor demos o using clinical scenarios 5 Choose the top two vendors based on demos Conduct organized reference checks based on standard x Continued on next page ADA Professional Product Review Continued from previous page questions Negotiate the best price for system and services Review and negotiate favorable contract and agreements Q If dentists buy products from different vendors for their EHR systems how can they make them work together smoothly A It s important to understand the differences between interfaced and integrated EHR systems By interfaced mean that the practice management system sits on one database and the EHR uses another database and they send information back and forth through an interface An integrated s
50. graphical bias for the observed L pneumophila antibody prevalence among locations across the United States So what does this tell us If we accept that L pneumophila is ubiquitous throughout the environment then dentists can come into contact with the bacterium like any other non dentist The source of exposure could be from a home shower head or water faucet public drinking fountains garden hoses or any other source where a fine spray or mist of warm water could be inhaled or otherwise aspirated Of course the source could also be from untreated dental unit water While L pneumophila in dental unit water may not be a significant source of disease transmission the Italian case report certainly shows that transmission can occur especially in elderly and other immunocompromised patients Furthermore there are a multitude of microbes some pathogenic capable of forming biofilms in dental unit water Many of these microbes can present an infectious hazard in immunocompromised patients Good infection control practices demand that dental unit water be as free from infectious contaminants as possible References 1 Centers for Disease Control and Prevention Recommendations and Reports Guidelines for Infection Control in Dental Health Care Settings 2003 MMWR Recomm Rep 2003 Dec 19 52 RR 17 1 61 http www ada org sections professionalResources pdfs quidelines_cdc_infection pdf Accessed March 25 2014 N Ricci ML Fon
51. illed Water AOE S v Nye J Considerably reduced microbial counts in Sterisil Straw 7 the dental unit water over the course of S365M for SHOCCaU mL 2 76 N A X the study however the 500 CFU mL limit Municipal Water was marginally exceeded near the product s capacity DentaPure DP365M Water i Purification BEE TDS gt 10 ppm at 61 Land HPC gt 500 CFU MOCE inl A ea S mL at 66 L allowing 1 week window for replacement Source water was pH 6 5 7 8 in accordance with the manufacturer stated optimal range of 6 5 8 5 Redox reaction however most likely absent with source x water of pH lt 8 device most likely more effective with water of pH gt 8 which iS impractical for most municipal water Supplies T uhh lt 1OCFU mL gt s N A J VistaClear gt 500CFU mL XC N A X Fails to meet the performance criterion based on experimental conditions v Passes the performance criterion based on experimental conditions Results Evaluation results are summarized in Table 4 Detailed information and other laboratory observations are described for each device following Table 4 Continued on next page Continued from previous page The AquaSept Heat Sterilizable Independent Water Delivery System effectively treated water throughout the evaluation The water exiting the test handpiece line was consistently less than 10 CFU mL over 103 use sterilization cycles compared t
52. ion Control helps your practice team stay informed about the prevention and control of infectious diseases This easy to follow guide includes a 40 minute DVD depicting actual clinical procedures and shows staff how to execute infection control techniques correctly safely and efficiently The corresponding workbook provides y more in depth coverage of the various r aoe g Effective Infection topics covered in the program ee P692 Book with DVD Members 135 00 Retail 202 50 Key features include What to do in case of possible exposure Updated infection control guidelines for to a bloodborne pathogen radiographic procedures The difference between disinfection Coverage of hand hygiene and care disinfection and sterilization of dental prostheses and impressions chairside a infection control and more The proper use and care of protective personal equipment P P _E Self assessment checklists to evaluate your ractice s current infection control practices Expanded section on the safe handling P P and disposal of needles and other sharps 8 hours of continuing education credit Order now and save 15 on all ADA Catalog products with promo code 14113 Offer expires 5 31 2014 For additional product details or to place an order visit adacatalog org or call 800 947 4746 Order your copy today and save ADA American Dental Association America s leading advocate for oral health ADA P
53. is test and control at 500 CFU mL to represent the maximum amount of bacteria supplied by a municipal tap water supply Products intended for use with deionized water were supplied with the same inoculation prepared in deionized water Although deionized water is unlikely to contain this level of bacteria the goal was to challenge each device with the worst case scenario as well as keep the test parameters consistent between the devices System Operation Systems operated at a flow rate of 25 mL minute for eight hours a day five days a week Table 3 Per the manufacturer the Sterisil System which had the greatest filter capacity to accommodate multiple dental operatories was operated at 100 mL minute to efficiently move water through the five filter cartridges Note Sterisil also stated that the flow rate sensor is not sensitive at 25 mL minute Manufacturers determine cartridge capacity liters of water treated by estimating the volume of water a dentist uses in daily practice over a given period of time In most cases this volume is estimated to be equivalent to one year of cartridge life Manufacturers use slightly different scenarios to report cartridge capacity such as 240 L or one year or 567 L or one year The ADA Laboratory estimated the average flow rate of a dental handpiece to be about 25 mL minute For example a 750 mL reservoir bottle that operated at a flow rate of 25 mL minute for 1 minute on and then
54. it blood or other potentially infectious materials to pass through to or reach the employee s work clothes street clothes undergarments skin eyes mouth or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used THE OSHA document OSHA Instruction Directive Number CPL 02 02 069 November 27 2001 a document used in inspections and enforcement states Paragraphs d 3 xi xii Requirements for the use of protective body clothing such as gowns aprons laboratory coats clinic jackets Surgical caps or shoe covers and the degree to which such PPE must resist penetration are performance based The employer must evaluate the task and the type of exposure expected and based on the determination select the appropriate personal protective clothing in accordance with paragraph d 3 i For example laboratory coats or gowns with long sleeves must be used for procedures in which exposure of the forearm to blood or OPIM is reasonably anticipated to occur Regarding scrubs the OSHA document states Scrubs are usually worn in a manner similar to street clothing and normally should be covered by appropriate gowns aprons or laboratory coats when splashes to skin or clothes are reasonably anticipated You can find more on the OSHA website s Most Frequently Asked Questions Concerning the Bloodborne Pathogens Standard www osha gov
55. la can be in dental unit water then dentists could acquire Legionella pneumophila occupationally The ADA Health Screening Program HSP held at various cities during the ADA s annual convention began looking at this issue about 10 years ago ending in 2012 HSP participants blood was assayed for the presence of L pneumophila antibodies subgroups 1 6 The results were surprising L pneumophila antibody prevalence among these dentists ranged from a low of 4 6 at the HSP held in Honolulu to a high of 22 at the HSP held in Philadelphia The average prevalence over 10 years was about 11 This is much higher than the current dentist antibody prevalence for the bloodborne pathogens HBV HCV and HIV However a small control group of non dentists surveyed at the same time showed approximately the same prevalence as dentists Although L pneumophila antibody prevalence was high evidence for occupational exposure was not strong Further analyses showed that exposure is unrelated to how often dentists monitored the microbial numbers in their dental unit waterlines or whether or not they reported cleaning their waterlines by one or more methods However L pneumophila exposure was strongly correlated with where a dentist lived Furthermore Legionella pneumophila antibody prevalence did not differ significantly between multiple visits to the same HSP location separated by at least four years This fact gives additional support to a geo
56. more information on infection control at ADA org igen Neve Glew eet Grerterg fo Verdier Wiebo bo fhe ADA Laway amp Archived ee imay Dea Late ADA American Dental Association America s leading advocate for oral health Information at your fingertips If you re an ADA member you have full text access to more than 280 journals through the ADA s Library amp Archives website Of these online journals 95 percent are dental related and the rest have a medical dental crossover Most articles in the collection were published in the past five years However some publishers allow access to older articles Members can search for articles through EbscoHost and the ADA reference librarians can help members who don t have experience searching databases Due to some license restrictions members would need to contact the Library to access some premium websites such as Wiley Online Science Direct and Quintessence Publications Members can view tables of contents and article abstracts from these premium sites and Library staff can immediately send PDF copies of the article via email Visit the ADA Library amp Archives website it s information at your fingertips Best Seller The ADA Practical Guide to Effective Infection Control Protect your patients and staff from the spread of disease with the most up to date infection control training from the ADA The newly revised ADA Practical Guide to Effective Infect
57. nder different operating conditions Thermocouples T type were placed at three locations on each individual handpiece head cap and motor Table 1 Operating conditions and settings for surface temperature measurements Step No Operating Condition Drive Air Chip Air Chip Water Duration a Handpiece OFF OFF OFF OFF Start Record eee i et a ge a TA Rei ar aaau aaa ea _ s p D T E AARRE z Ae ORANAN aee a ROLES Sa ee ae E peasant ee E cc IENA a aR a a a _ a y eee eee F TEA ee 7 Seer NE a ee ee eee eee asus ee i i a eh aa a seman eee eae coop RSMO aces SI ee pas ARDEA AETA AORA ae eu sence eae aie rrr eaten Aes teat os yes oe eee Soe ee ee oe gaa tt arin ee ae a The cutting time for each cut was the time it took to cut through a 38 mm long Macor ceramic block using a standard 557 bur and a 150 g weight to apply the cutting load To record the surface temperatures thermocouples were measure the ambient air conditions placed at three different locations on the handpiece head cap and motor Figure 1 A fourth thermocouple was placed near the handpiece during each test to Table 1 shows the operating conditions under which the surface temperatures were recorded At the beginning 2014 Volume 9 Issue 2 of a test investigators recorded the temperature Continued on next page ADA Professional Product Review Continued from previous page Temperature vs Time T H
58. ng storage Packaging materials e g wraps or container systems allow penetration of the sterilization agent and maintain Sterility of the processed item after sterilization Materials for maintaining sterility of instruments during transport and storage include wrapped perforated instrument cassettes peel pouches of plastic or paper and sterilization wraps i e woven and nonwoven Packaging materials should be designed for the type of sterilization process being used Can wear a short sleeve lab jacket when it s hot What does OSHA say about scrubs OSHA does not address dental office temperature and does not say when scrubs may be substituted or if at all It also does not state when clinic jackets or scrubs are to be worn But it does say when long sleeve clinic jackets are to be worn when exposure of the forearm to blood or other potentially infectious materials OPIM is reasonably anticipated to occur The OSHA Bloodborne Pathogen Standard 1910 1030 states Personal Protective Equipment Provision When there is occupational exposure the employer shall provide at no cost to the employee appropriate personal protective equipment such as but not limited to gloves gowns laboratory coats face shields or masks and eye protection and mouthpieces resuscitation bags pocket masks or other ventilation devices Personal protective equipment will be considered appropriate only if it does not perm
59. ntact with contaminated housekeeping or contact surfaces in the dental treatment area In order for a disinfectant to work however the surfaces must first be cleaned to remove any organic soil including blood and saliva DS What types of organisms do these products kill Dr John Tullner It depends on the level of the disinfectant for example whether it is intermediate John B Tullner DDS Dr Tullner is a graduate of the Baltimore College of Dental Surgery now the University of Maryland School of Dentistry and served three years in the U S Army Dental Corps as a general practice resident and staff dentist He served as the consultant for dental infection control to the VA Headquarters Office of Dentistry prior to his retirement as Chief of the Dental Service at the VA Medical Center Richmond Virginia with over 28 years of VA service Most recently he was an Adjunct Assistant Professor at the Virginia Commonwealth University School of Dentistry where he coordinated the Infection Control and OSHA programs Dr Tullner has lectured nationally and internationally on the practical application of dental infection control and the OSHA Bloodborne Pathogens Standard He is a Fellow of the International College of Dentists and is a member of the American Dental Association American Dental Education Association and the Organization for Safety Asepsis and Prevention OSAP or low level EPA approved intermediate level disinf
60. ntists encourage members who visit Chicago to stop by the ADA Headquarters and visit the laboratory to learn more about their research capabilities Dr David Sarrett the Review s editor 2 p 8 i To arrange a tour of the ADA contact Ms Bridget Baxter O at the ADA s toll free number at 800 621 8099 ext 2397 e ADA American Dental Association 8 America s leading advocate for oral health T N ADA Professional Product Review 8 Mailbox In this new feature we look at some of the most common questions the ADA s Division of Science receives each month from ADA members and their staff Must I bag all instruments What if use them as soon as they have been autoclaved Can bag instruments after sterilization An unwrapped cycle sometimes called flash sterilization is a method for sterilizing unwrapped patient care items for immediate use The U S Centers for Disease Control and Prevention CDC Guideline for Disinfection and Sterilization in Healthcare Facilities 2008 state Flash sterilization is considered acceptable for processing cleaned patient care items that cannot be packaged sterilized and stored before use It also is used when there is insufficient time to sterilize an item by the preferred package method Flash sterilization should not be used for reasons of convenience as an alternative to purchasing additional instrument sets or to save time When sterile
61. o the untreated control line which averaged 10 000 CFU mL AquaSept estimates the life of the sterilizable components to be 100 sterilization cycles After 103 use sterilization cycles the water outlet tubing of the test bottle exhibited tears in the medical grade silicone tubing rendering it unusable Figure 1 In clinical use the AquaSept tubing will most likely require replacement after about 5 months of daily sterilization The DentaPure DP365B Water Purification Cartridge replaces straw within reservoir bottle of delivery system effectively filtered 240 L water and maintained less than 10 CFU mL throughout the evaluation The control line HPC averaged 96 000 CFU mL Additionally the iodine level as measured with iodine test strips was greater than 1 5 ppm throughout the evaluation providing adequate disinfecting power The Sterisil Straw 365 for Distilled Water replaces straw within reservoir bottle of delivery system effectively filtered 240 L water and maintained less than 10 CFU mL throughout the evaluation The control line HPC averaged 96 000 CFU mL There was inadequate disinfectant capability of the Sterisil Straw S365M for Municipal Water replaces the pick up straw within reservoir bottle of delivery system when used with source water having 500 CFU mL and nearly 300 ppm TDS While the Sterisil Straw S365M did considerably reduce microbial counts in the dental unit water over the course of the study the 500 CF
62. ons for this issue one on dental unit water treatment systems and one on temperature rise in electric handpieces which can produce burns And if you re thinking of buying or updating your electronic health records system you ll want to read the article by Mike Uretz that looks at things to consider before moving forward I d like to hear from you What topics would you like to see covered in future issues Contact me at ppreditor ada org Surface Disinfectants What dentists and their staff need to know 2 en Seer Ree le et tt ec nee ie ate en ee z a a E EEEE gt a a a a a al macisie ieee a augue er re and the Associated Risk of Burns 18 a sineies Deacaiig mance reer oe neste eee General Considerations Before You Buy 25 Sia ADA American Dental Association ao tiinss coe 12678 America s leading advocate for oral health ISSN 1930 8736 ADA Professional Product Review Surface Disinfectants What dentists and their staff need to know Shannon E Mills DDS Dr Mills is vice president professional relations and science at Northeast Delta Dental in Concord New Hampshire He is a graduate of Baylor College of Dentistry and served as a dental officer in the U S Air Force in the United States and overseas He served as an Associate Professor in the Dental General Practice Residency at the University of Nevada School of Dental Medicine in Las Vegas He is recognized internationally as an expert on infection control and safety
63. oratory staff purchased and evaluated eight dental unit waterline treatment devices and one independent sterilizable water delivery system to determine which products deliver water that meets the EPA standard for potable water The devices evaluated here do not remove established biofilm and therefore are intended for use in either brand new installations or existing dental unit waterlines that have been treated to remove biofilm These devices treat water before it enters the unit to prevent the introduction of microbes and eventual establishment of biofilm Routine chemical treatment of the waterlines is not required by the manufacturer when one of these devices is used We also evaluated one portable dental unit with reservoir bottles and sterilizable tubing AquaSept Heat Sterilizable Independent Water Delivery System AquaSept Hudson Wis In addition to providing information on the efficacy of these products it is our goal to address practical issues especially since the initial investment in these products may be substantial 2014 Volume 9 Issue 2 Continued on next page Continued from previous page Table 1 Product Features According to Manufacturer Device Name and Manufacturer AquaSept Heat Sterilizable Independent Water Delivery System Cart AQUASEPT LLC Hudson WI 888 539 3907 www Aquasept com DentaPure DP365B Dental Unit Water Purification Cartridge MRLB INTERNATIONAL INC Fergus Falls
64. ouse or touch of a tablet From a clinical workflow standpoint an EHR system can manage task lists including the ability to alert for overdue tasks Electronic prescribing can allow all of a patient s prescriptions no matter what the source primary care specialist hospital to be presented in almost real time when the patient s chart is opened leading to better medication management and reduced liability Evidence based treatment planning and the introduction of clinical decision support tools can help a dentist access and incorporate the growing database of best dental practices Q How might dentists know what level of EHR system technology their practice needs p v A Analyze your current workflow and your desired 5 workflow This includes identifying your current steps vt for collecting entering and then accessing clinical 5 N Continued on next page ADA Professional Product Review Continued from previous page information during patient interactions Then document three clinical scenarios This can provide guidance to your selection committee and to potential vendors about daily usage needs for the software Define what software features are necessary for your daily practice as the must haves and what would be helpful or nice to have but not necessarily required If the software can t meet your must have list it should be considered less desirable and might even be eliminated from furth
65. rd with the objective of making the transition a success and using the new software efficiently on a day to day basis In a large group practice it may be difficult to get everyone involved in the decision making process In that case you can have departmental managers on the selection committee I ve seen many cases where the clinician prefers one vendor the billing person prefers another vendor and the scheduling front desk staff preferring yet a third vendor In cases like this it s helpful to prioritize the needs of the practice and work this out with the selection team Of course the practice owner always has the final say Q How should the team prioritize features in the selection process A Have the selection team members prioritize features that are important Think about features that are truly deal breakers and those features that are nice to have but not necessarily critical to the use of the system An example of a must have feature might be the ability to capture clinical documentation in the form of structured or individual data items whereas a nice to have feature might be a web patient portal The prioritization of features is especially important when comparing different vendors regarding specific features With a particular software application you might not get everything you need and by prioritizing it s easier to determine if a vendor has most of what you deem to be critical Q What about a pra
66. ridge for bottled water and the Sterisil Straws for both deionized and municipal water sources offer 90 day and 365 day models The purchase of a 365 day device will cost about 20 less than purchasing four 90 day devices Brief Summary of Results m The AquaSept Heat Sterilizable Independent Water Delivery System treated water effectively throughout the evaluation Disinfecting and sterilizing the inoculated bottle did not produce any colonies on agar throughout the evaluation m The DentaPure DP365B and the Sterisil Straw 365 filtered 240 L of water effectively maintaining HPCs of less than 10 CFU mL throughout the evaluation m When used with source water having 500 CFU mL and nearly 300 ppm TDS the Sterisil Straw S365M provided inadequate disinfectant capability While the product did considerably reduce microbial counts in the dental unit water over the course of the study the 500 CFU mL limit was marginally exceeded with an average of 1060 CFU mL near the product s capacity The untreated control line averaged 302 000 CFU mL m The DentaPure DP365M Water Purification Cartridge was highly effective throughout the evaluation with an average HPC of less than 10 CFU mL whereas the untreated control line averaged 46 000 CFU mL m The Sterisil System maintained effectiveness throughout the evaluation averaging less than 10 CFU mL whereas the control line averaged 46 000 CFU mL n each of the three trials VistaCle
67. rofessional Product Review Disease Transmission Through Dental Unit Water An Update Stephen E Gruninger or the past 20 years standard precautions have included a recommendation intended to limit dental unit water microbial contamination It is inconsistent to ignore dental unit water quality while strictly adhering to the use of personal protective equipment immunizations surface disinfection sterilization of instruments biohazard waste handling avoidance of percutaneous injuries and appropriate use of disposable supplies Intuitively keeping microbial numbers as low as possible is logical But where is the evidence that disease is transmitted by contaminated dental unit water to patient or provider We have some insight to that question in a 2012 case report in The Lancet The report described an elderly woman in Italy who acquired Legionella pneumophila infection after two visits to her dentist and subsequently died Legionella pneumophila subtype 1 was found in both the patient and in the dentist s high speed handpiece waterline Measured microbial numbers in the waterline were 62 000 CFU mL more than 120 times higher than the current CDC and ADA recommendation of 500 CFU mL Many studies have shown that different species of legionella can be identified in dental unit water but this was the first documented Legionella pneumophila fatality related to dental unit water You might speculate that if L pneumophi
68. tana S Pinci F Fiumana E Pedna MF Farolfi P Sabattini MA Scaturro M Pneumonia associated with a dental unit waterline Rome Italy Department of Infectious Parasitic and Immune Mediated Diseases Istituto Superiore di Sanita Lancet 2012 379 684 http www thelancet com journals lancet article PIISO140 6736 12 60074 9 fulltext article_upsell Accessed March 25 2014 WW Vogt KL Gruninger SE Kang P Siew C Meyer DM Occupational exposure to Legionella among dentists J Dental Res March 9 12 2005 84 Special Issue A https iadr confex com iadr 2005Balt print abstractbook8 html Accessed March 25 2014 B CG Estrich KL Vogt SE Gruninger 2014 Dental Practioners Risk Factors for Exposure to Legionella pneumophila J Dental Res March 19 22 2014 93 Special Issue A https iadr confex com iadr 43am webprogram Paper186560 html Accessed March 25 2014 A Laboratory Evaluation of Dental Unit Water Treatment Systems he U S Environmental Protection Agency s EPA Safe Drinking Water Act allows a maximum limit of 500 colony forming units per milliliter CFU mL heterotrophic bacteria However it is not uncommon for water from dental units to contain as much as 100 000 CFU mL greatly exceeding the maximum allowed for potable water The U S Centers for Disease Control and Prevention s Guidelines for Infection Control in Dental Health Care Settings recommend that water exiting the dental unit tre
69. to school for years to learn how to treat patients No one taught me how to evaluate electronic health records or choose software for my practice I m a bit stressed and confused The bottom line is that if you do your homework follow a stepwise organized evaluation and selection process and make a point to be in control every step of the way you can obtain a sophisticated next generation EHR system that meets the needs of your practice now and in the future Editor s note These articles are intended to be a resource and the views expressed are those of the authors and do not necessarily reflect the opinion or official policy of the ADA or its subsidiaries The articles contents are not a substitute for the dentist s own judgment and shall not be deemed an endorsement by the ADA Behind the Scenes Touring the ADA Laboratory The ADA Laboratory is housed in the Division of Science and includes dentists dental materials specialists microbiologists chemists and engineers and a machine shop Together this group develops and conducts tests and when necessary designs the equipment needed to adequately evaluate products which includes professional products used by dentists and some products in the ADA Seal of Acceptance Program The Laboratory also designs and applies new tests for the development and revision of standards and conducts research studies on critical and emerging issues of importance to practicing de
70. tric handpiece use To address concerns about hazardous handpiece temperatures ADA Laboratory scientists conducted an investigation to determine surface temperatures at various locations on seven electric handpieces The tests were performed as a preliminary investigation and could be used to establish baseline comparisons of typical surface temperatures on electric handpieces Temperature Measurements ADA investigators measured surface temperatures at various locations on handpieces from seven manufacturers EA 51LT A dec ELECTROtorque TLC KaVo Midwest eStylus Dentsply Professional NuTorque DentalEZ Group StarDental Micromotor MX Series Bien Air Ti Max NL 400 Brasseler and SIROTorque L Sirona Dental Systems Three handpieces were evaluated for each product Before testing the handpieces were subjected to 40 wear sterilization cycles One wear sterilization cycle consisted of having the individual handpiece make four cuts through a 38 mm long ceramic block specimen Macor Corning Inc using standard 557 burs anda 150 g weight to apply the cutting load investigators then applied cleaner and or lubricant according to the manufacturer s instructions Figure A B Patient burns caused by electric dental handpieces Continued on next page Continued from previous page Motor Thermocouple Head Thermocouple Figure 1 Typical test setup for measuring the surface temperature of electric handpieces u
71. ty and was instrumental in developing standards for structuring vendor contracts and pricing used by programs nationwide He regularly conducts next generation dental software and EHR workshops and seminars throughout the country and has published numerous dental software articles for industry publications and websites Editor s Note As a result of the Centers for Medicare amp Medicaid Services Medicare and Medicaid EHR Incentive Programs EHR Meaningful Use Incentives Program the term Electronic Health Record EHR is often used in a way to mean a particular information system or suite of systems that use various technologies standards and interfaces that work together to create manage store and share information associated with an electronic health record An EHR system for the dental practice or Electronic Dental Record system EDR would capture store present import and or export relevant extracts of patients longitudinal electronic health records A much desired feature of EHR systems is the ability to quickly and securely share health information with authorized providers across more than one healthcare organization or even across multiple healthcare settings regardless of the technology platforms involved Interoperable EHR systems offer the potential to improve care quality and patient safety by enhancing the quantity and quality of information available to providers for decision making An EHR system s abili
72. ty to capture detailed clinical information in a highly structured manner can enable analysis for quality assessment identification of areas for improvement and the design of decision support tools like allergy alerts medication alerts and other prompts In this article we talk with Mike Uretz an EHR educator and consultant and executive director of Dental Software Advisor www dentalsoftwareadvisor com Q What are some of the factors that dentists should think about when choosing or updating an electronic health record system A As more sophisticated EHR software computer hardware and digital dental devices are developed it s very easy for dentists practice managers and administrators to be confused by new technologies Even if you ve been using a satisfactory practice management system EHR technology is a different beast and is changing so quickly that not all software vendors are keeping up with new innovations The bottom line is that you need to be aware of and compare what s out there That said look at how EHR systems can help improve your patient care and communication streamline your clinical workflow improve your referral process and reduce overall practice liability Q What are some examples of more sophisticated EHR software computer hardware and digital devices A From a patient care standpoint the EHR system supports all pertinent medical and dental information available at the click of a m
73. used a standardized pricing template but this is not the case so the onus is on you to compare various proposals item by item You must understand all elements of a pricing proposal inside and out to properly compare prices can tell you that when evaluating different vendors it s not always apples to apples You don t want to get in a situation where you choose a dental software vendor implement the system and then proceed to be charged for every small thing after the fact Make sure when you compare vendor proposals that there s consistency between cost items and that different proposals specify similar products and services For example when comparing two vendors one proposal might have items related to software service and support while the other proposal might include software services support and the cost of an interface to your imaging system Try to determine what you need during the presales vendor evaluation process and convey this to the vendor so that the pricing proposal accurately reflects what items they intend to provide Q How can you organize and document all the information and factors you need to make an informed decision A Tie it all together with a Request for Proposal an Continued on next page Continued from previous page RFP RFPs are important because they Communicate your needs priorities and expectations Provide for side by side apples to apples vendor comparisons
74. ystem means that there is one database that holds all the practice management and clinical data so that there is no need to send information back and forth In terms of which is preferable if you interface one practice management system with another vendor s EHR system there s potential for finger pointing if there are issues There s also the possibility that both systems may change over time and interface issues might crop up If you look at the evolution of medical EHR technology over the last few years it has definitely moved from vendors interfacing with each other to more vendors now offering an integrated practice management and EHR system residing on one platform There are many other technical items to consider when comparing vendor systems that we can t cover in a Q amp A A dentist or practice manager might not have all the technical skill sets to evaluate the underlying technology in a particular vendor s EHR That s why IT geeks are there I d encourage you to engage a technical expert at least for a short while to help your EHR system decisions Q Once they ve picked out the products how do dentists go about getting the purchased components of the EHR system installed and working A This process can begin before the actual purchase if the practice compares implementation plans from different vendors and reviews this during reference checking There are situations in which a dental practice s op
75. zard to staff or patients on environmental surfaces DS Are all surface disinfectants alike JT Surface disinfectants are not alike They have varied chemical classifications each having pros and cons For instance while dilute sodium hypochlorite is an effective intermediate level disinfectant it can corrode certain metals Some surface disinfectants may be better cleaners containing surfactants than others A surface disinfectant that is also a good cleaner may help limit the number of products needed for surface disinfection in a dental practice SM No they re not all alike The effectiveness cleaning ability toxicity and compatibility with the surfaces to be disinfected varies widely among products Bleach for example is highly effective against a broad range of organisms and is non toxic It is however caustic at high concentrations corrosive to metals and can damage many other materials used in the manufacture of dental devices Shelf life how long the product is effective when stored unopened and use life how long a product 2014 Volume 9 Issue 2 is effective after being dispensed diluted or activated Continued on next page ADA Professional Product Review Continued from previous page and requirements for disposal also vary among products These considerations are all important when choosing the right disinfectant DS How do you know a product is ok to use SM A product that has an EPA R

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