What You Should Do If You Are Unable To Order Disinfectant Wipes

Over the last few months the dental industry has experienced shortages of supplies including masks, gloves, and other personal protective equipment (PPE). The PPE shortages have garnered national attention as hospitals and medical/dental facilities are competing for the short supply, as well as the public. But now…we have another problem–shortage of disinfectant wipes. While we want our supplies to last as long as possible, and look for creative alternatives, we need to make sure we’re doing so while ensuring patient safety and still remaining compliant with state laws.

Is There Really A Shortage? And Why?

The current supply chain issues regarding disinfectant wipes seem to be affecting several suppliers. The issues are not isolated to one company or one product. While many of the companies that supply infection control products have had increased demand over the past few months and are trying to ramp up to meet the demand, the problems seem to be a bit larger scale. Currently, there is a shortage of raw materials needed for disinfectant wipes including the plastic containers and the materials needed for the towelettes. For some companies, the materials needed for the towelettes are the same materials needed for masks, gowns, and other PPE. Combining a raw material shortage and increased public demand for disinfectants has created a huge problem in healthcare.

Are Wipes Acceptable for Use In The Dental Practice Setting?

First and foremost, it is always crucial to understand the manufacturer’s instructions for use and follow them. Many of the wipes on the market instruct the user to either spray with liquid disinfectant prior to using the wipe, or at lease clean the surface with one wipe first before using another wipe to disinfect. Similar to the “Spray-Wipe-Spray” method that we were taught in school, most products require a two-step process to clean first and then disinfect. It is important that we follow these instructions precisely when using the products to achieve the disinfection level shown by the clinical evidence.

The second factor we must consider is the amount of time for which the surface must stay wet. Each product has a specific amount of time required to kill both Mycobacterium Tuberculosis and SARS-COV-2. For the product to be effective for both of these, as well as the range of other pathogens in the dental practice, we must ensure that, again, we are following the instructions for use. The problem with some wipes on the market is that the saturation of the disinfectant is not high enough to keep the surface wet for the full amount of time required. In these cases, you would either need to supplement with a spray or liquid disinfectant or continue to wipe for the full amount of time required. Therefore, many practices over the years have continued to use liquid and spray disinfectants over wipes.

What Options Do We Have?

• Find a liquid or spray disinfectant that meets CDC requirements

In the 2003 “Guidelines for Infection Control in Dental Healthcare Settings”1, CDC requires use of an “intermediate level disinfectant” for all dental practice settings. Intermediate level disinfectants must have an EPA registration number and have a tuberculocidal claim. A complete list of products that meet these criteria can be found on the EPA List B2. In addition, CDC has released “Interim Infection Prevention and Control Guidance for Dental Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic”3 which states that a hospital grade disinfectant appropriate for SARS-CoV-2 in healthcare settings must be used for disinfection in the dental setting, which can be found on the EPA List N4. It is also important to look up the product by its EPA registration number, rather than its product name. Many products are sold under various names and may not show up under the brand name you are currently using in your practice.

• Use plastic barriers to protect clinical surfaces.

Since the “Guidelines for Infection Control in Dental Healthcare Settings” was published in 2003, CDC has recommended to use plastic barriers on all surfaces that are difficult to clean or unable to be adequately cleaned. “Barriers include clear plastic wrap, bags, sheets, tubing, and plastic-backed paper or other materials impervious to moisture” (Centers for Disease Control, 2003). Surfaces which have a plastic barrier covering them do NOT need to be disinfected in between patients if the surface is fully protected by the barrier and does not inadvertently become contaminated. Per the 2003 report, “After removing the barrier, examine the surface to make sure it did not become soiled inadvertently. The surface needs to be cleaned and disinfected only if contamination is evident. Otherwise, after removing gloves and performing hand hygiene, DHCP should place clean barriers on these surfaces before the next patient”

• Replace items with heat tolerant alternatives, when available.

Heat sterilization methods are the gold standard when preventing transmission of pathogens in the healthcare setting. Many items used for patient care in the dental setting can be heat sterilized. Whenever possible, use items that are heat tolerant and can be heat sterilized. Consider replacing items in your practice with heat tolerant alternatives to minimize transmission and simplify infection control procedures between patients.

• Prioritize treatments to reduce patient load in your practice to conserve supplies.

If all other options have been exhausted and your practice is still unable to comply with CDC recommendations and/or state laws, the last option would be to prioritize treatments within your practice to reduce the overall volume of your practice and minimize the amount of infection control products required.

Mistakes To Avoid

• Soaking gauze in liquid disinfectant.

Pre-soaking gauze in disinfectant can inactivate ingredients in disinfectants compromising the efficacy of the disinfectant. Both CDC and the Organization for Asepsis and Prevention (OSAP) have stated that they do not support pre-soaking gauze in disinfectant prior to use. In a study cited by the CDC, pre-soaking gauze showed a decline in effectiveness of 40 to 50 percent after only one hour of soaking in a quaternary ammonium disinfectant.5 Another study cited by the CDC shows gram-negative bacteria can survive and even grow when other disinfectants (phenolics, iodophors) are pre-soaked in gauze5. OSAP says if you are going to use gauze with disinfectant, it should be saturated with the disinfecting agent at the time of use.6

• Making your own disinfectant.

Outdated recommendations from 1993 seem to be circulating which encourage dental healthcare providers (DHCP) to create solutions of sodium hypochlorite in office. The 1993 “CDC Guidelines on Infection Control in the Dental Setting” provided instructions on how to create a daily dilution of household bleach as an acceptable alternative to commercially available hospital disinfectants. However, the 2003 guidelines state that over-the-counter products cannot be used as disinfectants in healthcare facilities. All products used in the dental setting must be EPA registered and meet the criteria previously discussed.

• Relaxing infection control protocols because of supply chain issues.

Many state practice acts and/or rules set forth by the boards of dentistry require DHCPs to comply with CDC recommendations. CDC recommendations from 2003 and 2016 both state that only intermediate level disinfectants should be used in the dental setting. Even when not explicitly required by state laws or rules, it is important that DHCPs continue to adhere to evidence based infection control practices for the safety of patients and employees. We all understand the pressures on our practices right now, but it is more important than ever that we remain diligent with our infection control practices. Both legally, and ethically, we are required to implement these practices.

References

1. Kohn, W.G., Collins, A.S., Cleveland, J.L., Harte, J.A., Eklunt, K.J., Malvitz, D.M. Center for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings – 2003. MMWR 2003; 52 (Report No. 17). Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm
2. List B: EPA’s Registered Tuberculocide Products Effective Against Mycobacterium tuberculosis. United States Environmental Protection Agency. 6 pp, 200 K, July 21, 2020. Retrieved from https://www.epa.gov/pesticide-registration/list-b-epas-registered-tuberculocide-products-effective-against-mycobacterium
3. “Interim Infection Prevention and Control Guidance for Dental Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic”. Updated August 4, 2020. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html
4. “List N: Disinfectants for Use Against SARS-CoV-2 (COVID-19)”. United States Environmental Protection Agency. Updated August 13, 2020. Retrieved from https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19.
5. Centers for Disease Control and Prevention. Guideline for Disinfection and Sterilization in Healthcare Facilities – 2008. Updated: September 18, 2016. Retrieved from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/chemical.html
6. Organization for Asepsis and Prevention (OSAP). Frequently Asked Questions on Dental Infection Control. Retrieved from http://www.osap.org/?FAQ_Instrum_Disinf1#ireadrecently