INSTRUMENT SETS

Modern dental operatories do not include large storage areas. Practitioners store instruments in the sterilization area and take them to the appropriate operatory as needed for each patient. This allows smaller operatories with less cabinetry. It also requires fewer instrument kits because practitioners do not need to store multiple copies of each kit in each operatory. As the number of procedures increases or changes over time, the office can add or change instrument kits in response.

There are two standard methods of distributing instrument sets to the operatories: trays and cassettes. The staff must package instruments from trays for sterilization and then reset fresh trays with sterile instruments. This involves additional staff time and increases the possibility of injury each time they handle instruments. Cassettes have the advantage that hands do not touch the instruments. Staff members can place the entire cassette in the cleaner and then the autoclave. Cassettes carry a higher initial cost than trays. Dental offices also need a larger (more expensive) autoclave to accept cassettes (particularly large cassettes) over bagged instruments. Cassettes should be color‐coded or have colored tape or other markers applied to show the types of instruments contained (e.g. operative, or endodontic).

Plastic tubs (color‐coded) contain all the special materials needed for a procedure. These materials and equipment are non‐critical instruments that do not need sterilization after use. For example, an endodontic tub contains sealers, points, and other supplies used in endodontic procedures. If an instrument does need sterilization, it is placed into a separate tray or cassette for processing.

NUMBER OF INSTRUMENT SETS AND TYPES NEEDED

Several factors dictate the number and type of instrument set‐ups a practitioner needs. A practitioner does not want to run out of instrument set‐ups, but they also do not want to have too many set‐ups, because they are expensive. First, the practitioner determines the office instrument processing cycle. Many offices process once per day. Others process twice daily (at lunchtime and again at the end of the day). Larger offices that have a dedicated sterilization clerk will process instruments continually. Next, the practitioner estimates the number of patient visits per processing cycle. If the hygienist sees a patient for an hour and the office processes instruments every four hours, they need a minimum of four hygiene set‐ups. If the practitioner might do two endodontic procedures in a cycle, then they need a minimum of two endodontic set‐ups. Once the practitioner decides the minimum number of instrument sets they need, they should add 50%. (For example, if the practitioner decides they need six operative sets, they should get nine.) This covers a hectic day, processing backlogs, or the possibility of a set being dropped or otherwise deemed unusable.

INSTRUMENTS WITHIN THE SETS

The practitioner needs to decide the specific instruments they want within each set of instruments. They ought to use the minimum number that gives excellent results. Dental suppliers have instrument markers (small plastic rings that fit securely on dental instruments). The practitioner should get a different color for each type of set‐up (e.g. blue for operative, green for prophy). Within those set‐ups, the employees place the instruments in the order in which they will use them. Place the color‐coded bands on the instruments in descending order. This method allows staff to quickly put the instruments in the proper order and decide if any instruments are missing during processing.

STAFF CONSIDERATIONS

As previously mentioned, OSHA requirements dictate instrument processing procedures. Practice owners must train and monitor dental healthcare personnel (DHCP) for properly performing procedures. They must wear PPE and thick protective gloves (not patient care gloves) when they process instruments.

Larger offices often have staff members whose only job is to process instruments. In these offices, instrument processing will be a continuous procedure. Many smaller offices do not need to process instruments constantly. Instead, they process instruments at several points in the daily routine, often at lunchtime or the end of the day. Some offices make each staff member responsible for cleaning and packaging their own instruments. Others make one staff member responsible for all the processing.

OFFICE DESIGN CONSIDERATIONS

The design of an office needs to provide for easy transportation of instruments to and from the sterilization area. Therefore, it ought to be centrally placed near the operatory patient areas. Ideally, it should have a separate traffic pattern from patients so that patients cannot be in contact with dirty instruments or wander into the sterilization area.

The size of the sterilization area will vary with the available floor space, the number of operatories, and normal patient flow. It needs to have ample counter space (at least 10 linear feet) and needs to be divided into “dirty” and “sterile” sides. Dirty instruments stay only on their side, and sterile instruments on theirs. (Some offices use signs or tape on the counters to designate clean and dirty areas in the sterilization room.) Storage for dirty instruments (trays or cassettes) must never mingle with storage of clean trays or cassettes. Storage cabinets will ideally have clear plastic doors that can be quickly taken apart and cleaned. There must be a large, deep sink with a spray attachment on the dirty side of the counter.

The instrument processing area must allow instruments to flow in a single loop for optimal workflow and aseptic technique. The staff bring contaminated instruments into the area, clean, package, sterilize, and store them continuously, like on an assembly line. The more automated the process becomes, the less chance there is for operator error in processing. The sterilization area must be separate, not shared or mingled with other functions. Some small offices combine the dental lab or general storage area with the sterilization area. This invites cross‐contamination. Although space limitations may dictate some compromises, the practice owner should try to keep a dedicated area for instrument processing. OSHA guidelines require an approved eyewash station in the instrument processing area. That are should also have compressed air and vacuum lines for cleaning and lubricating handpieces before sterilization.

OPERATORY BREAKDOWN

The practice owner needs to schedule enough time (10 minutes) at the end of each appointment for operatory breakdown, cleaning, and set‐up. DHCP should place all sharps into an approved and labeled sharps container. They should place all soaked or saturated material and all tissue (teeth or surgically removed tissue) into appropriate biohazard bags. They may put all other waste into the waste system. Before transferring instruments to the processing area, they must place them in covered containers. DHCP then disinfect smooth surfaces and remove and discard barriers.

In the dental operatory, surfaces that do not touch the patient can still become contaminated with saliva, blood, or another infectious residue. Their likelihood of having any infectious residue dictates their cleaning method. The CDC classifies them as either clinical or housekeeping surfaces (Box 27.9).

Housekeeping surfaces, such as floors, walls, and sinks, have a limited risk of disease transmission. Dental practice employees decontaminate them with less rigorous methods than patient care or clinical surfaces. Most of these surfaces only need to be cleaned with a detergent and water, or hospital disinfectant approved by the Environmental Protection Agency (EPA). Thorough cleaning once a day is more important for these surfaces than disinfection (Box 27.10).