The Dental Advisor

Preventing pathogen transmission among patients and dental health care personnel is the primary goal of infection prevention in the dental office. During the course of the work day, clinicians repeatedly perform hand hygiene, wear personal protective equipment, clean and disinfect surfaces (or apply surface barriers), sterilize instruments, maintain dental unit waterlines, and use single-use disposable items. These tasks often involve equipment and products that produce much waste, consume excess energy, and use toxic chemicals.

Environmental issues became a major concern in the late 1900s when people recognized their actions were negatively affecting the earth. People began to examine their role in pollution, rampant use of natural resources and occupied space in landfills. The 

 introduced the strategies “reduce, reuse and recycle” to help sustain the earth for future generations. “Re-think” is a fourth strategy recently presented into this hierarchy- to promote eco-friendly choices over traditional practices.? At first glance, the principles of “infection prevention” and “eco-friendly” seem to be mutually exclusive and at odds. However, recent technological and manufacturing advancements are making these areas more compatible.

There are multiple goals associated with eco-friendly infection control. They include: prevent infection transmission in health care settings; improve safety for employees; and preserve and improve the environment. To accomplish this, a combination of traditional and environmentally friendly products, supplies and procedures are available.

 Chris Miller, PhD, was the first to develop a list that considered properties and features in the context of green infection control “do’s and don’ts” as they relate to recyclable and biodegradable materials, energy and water conservation, waste management, and maintenance of infection control standards.

 These considerations give manufacturers and consumers general guidelines for product development, evaluation and use (See Eco-Friendly Dos and Dont’s sidebar).

Multiple studies conducted in hospitals show that care for an average patient could generate about 15 pounds of paper and plastic waste per day.

 Much of this comes from single-use disposable items and devices. Unfortunately, these items are occupying space in landfills, as well as consuming energy during manufacturing. Clearly, effective compromises are necessary to maintain an eco-friendly mindset while not compromising patient safety and care. Clinicians should evaluate the advantages and disadvantages of these items during product selection.

Some single-use disposable items may be biodegradable, may be manufactured from recycled materials and/or are lead free. These include environmental surface barriers, sterilization pouches with lead free indicators, wraps (secured with lead-free tape), and plastic air-water syringe tips. Reusable metal air-water syringe tips are difficult to clean before heat sterilization. Studies show they may not even be free of accumulated bioburden after reprocessing. Because initial cleaning remains at the core of infection control principles and practices, inability to remove debris from used air-water syringe tips before sterilization reinforces a disposable approach. Published infection control recommendations and regulations clearly state to not reprocess and reuse products that are meant for single use only. These products cannot be reliably cleaned, are not heat tolerant, and must be discarded after a single use. Many single-use items will exhibit the universal symbol of a single use disposable item: “2” with a slash through it. Sterilization products, such as wraps and pouches, are manufactured and approved for single use only and do not exhibit this symbol.

			May require additional resources to clean (electricity, water, soap)

In the past, chemicals used for infection control prevention were fast acting and effective at killing harmful microorganisms. Choices were limited and toxic to the environment. Chemicals used for cleaning and disinfecting in dental facilities often produce volatile organic compounds (VOCs) that effect indoor air quality. And, although chemicals are supposed to be handled, used, and disposed of according to governmental regulations, they’re often flushed down the drain. Water treatment facilities, unfortunately, can’t remove all chemicals from influent water. These chemicals are released into surface waters.6

Environmentally friendly chemical options include products that are less toxic, contain fewer VOCs, are easily disposed of, and are biodegradable.

 Thanks to technology, there are now multiple products that may be categorized in this manner. For example, there are instrument pre-cleaners and ultrasonic cleaning solutions that contain one or more enzymes to enhance removal of organic debris from contaminated instruments. Included are: 

, a dual proteolytic ultrasonic cleaner; and Hu-Friedy’s Enzymax Earth, a dual-proteolytic and amylase ultrasonic cleaner. By facilitating rapid breakdown of adherent bioburden into water-soluble components, these enzymatic preparations efficiently clean difficult-to-remove debris from instruments. This type of solution is biodegradable because of its proteinaceous composition. With the addition of an amylase component, degradation of carbohydrate components in plaque, blood and saliva also can be enhanced.

Other areas of infection control prevention have seen more eco-friendly products. The development of a hydrogen peroxide based intermediate level disinfectant for environmental surfaces such as 

allows for an effective disinfectant that degrades to form water. Dental unit waterline asepsis can be accomplished using a complete system such as Hu-Friedy’s Team Vista. The system includes a cleaner that is free of heavy metals (VistaTab) and a maintenance product derived from organic botanicals (VistaClean).

Clinicians face daily choices with regard to chemical selection, usage and disposal. When considering options that are less toxic, biodegradable, and contain fewer volatile organic compounds, be aware that all products used for disinfection and sterilization must be EPA registered and discarded or recycled according to detailed governmental regulations. Whether traditional products or eco-friendly alternatives chosen, clinicians must have a basic understanding of the chemicals used in their facility and the MSDS data accompanying them. Never assume one product will be used exactly as a similar alternative.

There is growing evidence of global climate changes and finite capacity of our planet’s eco-system. All members of society are encouraged to “reduce, reuse, recycle and rethink” as we evaluate our lifestyle choices and attempt to sustain the environment for future generations. Dental facilities can participate in these environmental efforts. Eco-friendly infection prevention applications involve careful consideration of product selection and practices, observing correct waste management methods, and a team effort. Remember your first priority is preventing infection transmission. When products are selected, used, and disposed of judiciously, while at the same time maintaining infection control standards, it is a win-win for all involved.

For more on the Hu-Friedy products mentioned in this article ...

1. Pockrass F, Pockrass I. The four “R’s” of eco-friendly dentistry. Access. 2008: 22 (8): 18-21.

2. DiMatteo, Going Green: Making your Practice a Green and Eco-Friendly Machine, Inside Dentistry, April 2010, Vol. 6, Issue

5. Miller, Palenik. Infection Control and Management of Hazardous Materials for the Dental Team, 4th Edition. Chapter 23: Greener Infection Control, Mosby, 2009.

6. Molinari, Infection control going green: oncoming reality-Part 1, 

7. Molinari, Harte, Practical Infection Control in Dentistry, Third edition, Chapter 17: The Role for Single-Use Disposable Items, Lippincott Williams & Wilkins, 2010.

9. Sawchuk, Green Disinfectants and Pathogenic Organisms, 

Articles

Implementing eco-friendly infection control

	The characteristics of high-pitched noise, reduction in torque under load and vibration of the bur, often associated with air-driven handpieces, are being replaced by the quieter, smoother and concentric motion of electric handpiece systems. Electric handpiece systems have taken dental handpieces to new levels of performance by offering advances in torque control, power, noise level, illumination, concentricity of movement, lubrication and maintenance.

	Doctors use a handpiece for every procedure in the office. It is critical to have this instrument perform without breakdown during operation. Handpiece sizes have evolved to smaller head sizes and the introduction of multi-directional, multi-speed electric handpieces allowed dentists to have slowspeed control with highspeed power and torque. Electric handpiece systems offer high torque, low vibration and quieter operation. The ability to maintain a constant speed under load is what gives the electric handpiece the power advantage.


	Constant speed and torque
	Concentric cutting
	Quietness during operation
	Versatility for multiple types of procedures
	Manual control of operating speed
	Excellent optics
	Consistent water spray
	
	KaVo COMFORTdrive offers a no-bur-stall feature and exceptional bur concentricity for improved efficiency. One of the greatest complaints of clinicians converting to electric handpiece systems was the increased weight as compared with air-driven handpieces. KaVo COMFORTdrive was evaluated to be lightweight as well as ergonomic while offering the power and torque one would expect from an electric handpiece. The handpiece features an integrated sterilizable motor that provides consistent performance while reducing the distal area length after the pivot point in the doctor’s hand, allowing for comfort and control. The KaVo COMFORTdrive operates at 55 dB and all evaluators reported it to be the quietest handpiece they had ever used. The handpiece delivers excellent fiber optic light output. The system is designed for easy setup with no learning curve and doctors using air-driven handpieces can seamlessly make the transition. The handpieces were easy to maintain on a QUATTROcare handpiece maintenance system with the COMFORTdrive adapter. KaVo COMFORTdrive is designed for precision cutting and quieter operation and all evaluators indicated they would recommend this handpiece to a colleague.

 The characteristics of high-pitched noise, reduction in torque under load and vibration of the bur, often associated with air-driven handpieces, are being replaced by the quieter, smoother and concentric motion of electric handpiece systems.

Benchmark: KaVo Dental's COMFORTdrive handpiece

	At THE DENTAL ADVISOR, our group has been researching and tracking all-ceramic restorations for 28 years. As ceramics have evolved, there is a move toward stronger and more esthetic materials.

	As we educate both doctors and laboratories on the evolution of all-ceramic materials, the focus lately has been on zirconia versus lithium disilicate. Depending on the clinical situation, both materials offer excellent esthetics and provide long-lasting results. So why all the hype?

	Currently, zirconia has the highest flexural strength of any all-ceramic material. The advantages of zirconia over other materials are it is biocompatible, it is less expensive than using metal and it offers excellent esthetics.

	Probably the most popular question posed to us at lectures and on our website is about zirconia fracture. It has been said many times, but should be clarified that the reported fractures are of the overlaid porcelain, not the zirconia substructure. Early on, fractures were reported because of a number of factors: poor coping design, improper mixing of overlay porcelains, improper firing, and poor preparation by doctors.

	In response to the fracture and chipping issue, considerable attention has been given to educating both doctors and technicians on the use of the material. In fact, laboratories are now realizing that with the fixed price of zirconia, support of porcelain can be emphasized during substructure design, rather than minimizing metal to keep restoration costs down.

	In addition, because of zirconia’s excellent biocompatibility and strength, we are starting to see more and more interest in and use of full-contour zirconia restorations in lieu of full-contour metal or metal occlusal restorations. 

	THE DENTAL ADVISOR is proud to be the only organization worldwide that has clinically tracked restorations on 3M ESPE’s Lava zirconia for the past 7 years.  We recently published the study of more than 1,500 porcelain fused to zirconia (PFZ) restorations placed during the past 7 years. Five hundred seventy-four were recalled for this study and highlights from the results include:

	Of the recalled restorations, 16 (2.7%) were replaced because they received a rating of 1 or 2 out of 5. In these cases porcelain delaminations were significant enough that they could not be acceptably smoothed or polished. Thirty-five restorations (6%) received a rating of 3 or 4. These were chipped restorations that either did not need any smoothing or polishing or could be polished and smoothed satisfactorily.

	The majority of the recalled restorations had excellent esthetics, and 57 restorations (10%) had a good to very good rating.

	More than 95% of Lava restorations received an excellent rating for resistance to marginal discoloration. During the 7-year evaluation, only 2.8% of the restorations exhibited slight graying at the margins.

	More than 96% of Lava restorations received an excellent rating for resistance to wear. A small number (3.2%) of the recalled restorations exhibited some wear of the overlaid ceramic at 7 years.

dentaladvisor.com/clinical-evaluations/evaluations/3m-espe-lava-crowns-and-bridges-7-yr.shtml

For nearly 30 years, THE DENTAL ADVISOR has been reporting on dental materials and equipment for the dental profession. The Long View is designed to report on clinical performance over time. This is a key metric desired by clinicians and technicians when choosing a product.

With doctors often asking questions regarding the right material to choose in a given clinical situation, THE DENTAL ADVISOR is available as a resource and would be glad to assist you. Visit THE DENTAL ADVISOR at 

Apex Dental Milling is a premier dental milling facility operating multiple dental CAD/CAM systems and capable of working with the ever expanding range of materials. As a partner of THE DENTAL ADVISOR, Apex Dental Milling offers valuable insight and consulting on CAD/CAM from the laboratory viewpoint.

 At THE DENTAL ADVISOR, our group has been researching and tracking all-ceramic restorations for 28 years. As ceramics have evolved, there is a move toward stronger and more esthetic materials.