Easy ways to avoid harmful x-ray exposure
Dental x-rays are critical to evaluating and diagnosing many oral diseases and conditions. Although radiation exposure from x-rays is low, the effects can accumulate from multiple sources over time. Limiting radiation exposure can be achieved through these simple techniques:
PROTECTING THE PATIENT
Obtaining and reviewing previous full-mouth series or panoramic x-rays can eliminate the need to take new radiographs. For example, patients with stable periodontal health and a low caries rate may be able to increase the time between bitewings from annually to every 18 to 24 months years (ADA, 2012). If new radiographs are necessary, radiation exposure can be decreased through the use of higher film speeds, shielding, and collimation.
HIGHER FILM SPEEDS: Using the fastest film available significantly reduces radiation exposure. Currently, intraoral X-ray film is available in three speeds: D, E, and F. E-speed film is almost twice as fast as D-speed film—and about 50 times faster than traditional x-ray film. F-speed film requires about 25% less exposure than E-speed film and 60% less exposure than D-speed film. Multiple studies have confirmed that F-speed film has the same useful density range, latitude, contrast, and image quality as D- and E-speed films, and it can be used in routine intraoral radiographic examination without sacrificing diagnostic information (ADA, 2012).
SHIELDING: The use of aprons and thyroid collars shields the gonads and thyroid gland from radiation exposure, which is particularly important among vulnerable populations, such as children and pregnant women. The ADA recommends that every patient should be covered with an apron. When taking routine bitewing and periapical radiographs, a thyroid collar should be used. Panoramic imaging is an exception to the rule; a thyroid collar can obscure large areas of the target zone (ADA, 2012).
COLLIMATION: A collimator is a metallic barrier with an opening in the middle that is used to reduce the size of the x-ray beam, and, thus, the exposure area. Dental x-ray beams are usually collimated to a circle 2¾” in diameter. When an x-ray beam is directed at a patient, the hard and soft tissue absorbs about 90% of the photons, while approximately 10% passes through the patient and reaches the film (ADA, 2012).
PROTECTING THE OPERATOR
Although dental professionals receive less exposure to ionizing radiation than do other occupationally-exposed healthcare workers, operator protection measures are essential to minimize exposure. Protective measures include the use of barrier shielding, occupational radiation exposure limits, and personal dosimeters.
SHIELDING: When possible, operators of radiographic equipment should use barrier protection, and barriers should ideally contain a leaded glass window to enable the operator to view the patient during exposure. When shielding is not possible, the operator should stand at least two meters from the tube head and out of the path of the primary beam.
EXPOSURE LIMITS & PERSONAL DOSMITERS: The maximum permissible annual dose of ionizing radiation for health care workers is 50 millisieverts (mSv) and the maximum permissible lifetime dose is 10 mSv multiplied by a person’s age in years. Personal dosimeters must be used by workers who may receive an annual dose greater than 1 mSv to monitor their exposure levels. Pregnant dental personnel operating x-ray equipment must also use personal dosimeters, regardless of anticipated exposure levels (ADA, 2012).
PureLife now offers personal dosimeters that measure the amount of high energy ionizing radiation a person has been exposed to. The PureLife Radiation Detection Badge is a small, reliable badge designed for superior accuracy, easy handling and cleanliness.
Dentistry: It’s Risky Business
Reduce the risk of occupational hazards by avoiding chemical culprits
In addition to infectious diseases and muscle injuries, dental professionals encounter a number of workplace hazards. Dental staff are exposed to toxic chemicals throughout the day, including those found in products used to clean and disinfect instruments and surfaces. Long-term exposure can increase the risk for developing life-threatening diseases and allergies, which is why it’s important to take the necessary precautions when working with these chemical hazards:
USES/MATERIALS: Glutaraldehyde is widely used as a cold sterilant to disinfect and clean heat-sensitive equipment. It is found in desensitizers, high-level disinfectants and sterilants.
RISKS: Glutaraldehyde is toxic and a strong irritant. Exposure to glutaraldehyde causes severe eye, nose, and throat irritation, as well as headaches and drowsiness. It is the main source of occupational asthma among healthcare providers.
ALTERNATIVES: Glutaraldehyde-free desensitizers and high-level disinfectant solutions are available. Teethmate Desensitizer from Kuraray delivers sensitivity relief by creating hydroxyapatite to seal dentinal tubules and cracks in enamel. Sporox II from Sultan is a powerful hydrogen peroxide-based sterilant and high-level disinfectant for heat-sensitive instruments. Cidex OPA from Johnson & Johnson and Rapicide OPA/28 HLD from Crosstex are high-level disinfectants with rapid high-level disinfection times – nearly nine times faster than glutaraldehyde-based solutions.
USES/MATERIALS: Phenols are used as a disinfectant and antiseptic and can be found in some infection control products, including surface disinfectants.
RISKS: The Environmental Protection Agency lists disinfectants that contain phenols as “corrosive and toxic.” Exposure to phenols causes irritation of the skin, eyes and mucous membranes.
ALTERNATIVES: PureLife does not carry any products that contain phenol. Alternatives include BioSURF Surface Disinfectant from Micrylium, which kills TB in 50 seconds and does not contain any harmful phenols or aldehydes, and CaviCide1 from Kerr TotalCare, which has a 1-minute TB kill time and is fragrance-free, bleach-free and phenol-free.
USES/MATERIALS: Triclosan is an antibacterial agent found in many hygiene products, including toothpastes, hand soaps, hand sanitizers and lotions.
RISKS: Studies have suggested that triclosan may disrupt hormones that play an important role in reproduction and development, while other research indicates that triclosan may contribute to the development of drug-resistant bacteria. The FDA is currently evaluating its safety, but has found no evidence to support triclosan as being more effective than plain soap and water in preventing the spread of diseases. Minnesota has already passed a bill that will ban the use of triclosan in most retail hygiene products beginning in 2017.
ALTERNATIVES: Toothpastes that contain stannous fluoride, including all Crest toothpastes, are effective alternatives to triclosan. Purell® Green Certified Instant Hand Sanitizer from GOJO USA and Gibraltar Barrier Cream from Micrylium are triclosan-free hand care products that also contain moisturizers to condition skin.
USES/MATERIALS: Latex is most commonly found in gloves. Other dental materials that contain latex include latex dams, gutta-percha, mixing bowls, orthodontic elastics, some suction tips, bite blocks and amalgam carriers.
RISKS: Healthcare workers exposed to latex gloves and other latex-containing medical devices are at risk of developing latex allergy. Adverse reactions can be classified as true latex allergy (Type I hypersensitivity) or allergic contact dermatitis (Type IV hypersensitivity). True latex allergy is a reaction to the latex proteins. These proteins can infiltrate the body through skin and mucosa. Reactions can range from erythema and hives to anaphylaxis, a potentially life-threatening condition. Conversely, allergic contact dermatitis is a reaction to the chemical additives used in the manufacture of latex gloves. Symptoms take several hours to develop, and include swelling, redness, itching, and blistering/cracking of the skin.
ALTERNATIVES: Staff with true latex allergy require the use of non-latex gloves, such as nitrile, neoprene or vinyl. Staff with allergic contact dermatitis require the use of vinyl gloves, as nitrile and neoprene gloves contain the same chemical additives found in latex gloves.
The Downfall of Reusing Disposables
If one line of defense tumbles, the rest will likely follow
In recent years, disposable products have become the gold standard of infection control protocol. These single-use items are intended to be used on one patient and discarded. They should not be sterilized in an autoclave due to the heat-intolerance of their materials. Compared to reusable (or multi-use) products, disposable products reduce the probability of patient-to-patient cross-contamination and potential cross-infection.
In the not-so-distant past, “reusable” was more common than “disposable.” You may even remember when procedural items, such as saliva ejectors and prophy cups, were cleaned and sterilized to be reused on another patient. Since then, the FDA has repeatedly stated that it is unaware of any data that would establish safe and effective cleaning/sterilization conditions necessary for reuse of any disposable device (OSAP, 2012). Similarly, the CDC advises using single-use devices on one patient only and disposing of them appropriately. However, it is still generally accepted by dental professionals that many single-use products are safe to reuse if sterilized, such as…
Whether burs are single-use or multi-use remains a contested issue. Cleaning can be difficult due to burs’ intricate physical construction, and repeated processing cycles can deteriorate the cutting surfaces enough to potentially break during patient treatment. These factors, coupled with the knowledge that burs exhibit signs of wear during normal use, might make it practical to consider them single-use. A fair amount of resources are spent scrubbing burs and diamonds prior to sterilization, which equates to longer intervals between patients. From an infection control viewpoint, treating burs as single-use eliminates the risk of patient–to-patient cross–infection.
DISPOSABLE MOUTH MIRRORS
Plastic mouth mirrors are great alternatives to traditional mouth mirrors in that they significantly reduce cross-contamination. However, they are not meant to be reused and their plastic materials are not suitable for the autoclave. Because mouth mirrors are inserted directly into the patient’s mouth, improper sterilization practices can greatly increase the risk of patient-to-patient cross-infection.
Unlike most disposable items, which are single-use in the sense that they may only be used on one patient, face masks are only as effective as their designated time limit. The length of time that a mask protects against infection and cross-contamination depends on its ASTM level (according to FDA guidelines):
ASTM Level 1: 15-20 minutes
ASTM Level 2: 30-40 minutes
ASTM Level 3: 60+ minutes
Why the wide discrepancy between what is regulated and what occurs in the practice? For one, complying with every OSHA regulation and CDC guideline is easier said than done. And, because devices that were considered reusable twenty years ago are now deemed one-time use, adapting to new practices is slow to change. Plus, the misconception that disposables cost more could explain the discrepancy. On average, a dentist spends $20 in disposables to set up an operatory, which fluctuates depending on the number of patients seen per day.
However, the monetary savings gained by reusing disposables are minor when compared to the huge costs of an infection control breach. Although reuse of common disposable items may seem harmless, little things can accrue to a big problem. When it comes to infection control, loosening the slack in one area lessens the overlap and effectiveness of your total chain of infection control. Think of it as a line of dominos — once the first one falls, the rest fall along with it.
At PureLife, you don’t have to risk sacrificing your line of infection control defenses to achieve a happy bottom line. We offer a wide variety of top-quality, cost-competitive disposable items for any procedure. Call us at 877-777-3303 or visit PureLifeDental.com for our complete list of disposables.
The Root Cause
The dental professional’s guide to latex glove allergies
Natural rubber latex is a material found in many dental supplies—mainly exam gloves. In the past decade, there has been a significant increase in the number of healthcare professionals reporting allergic reactions to latex. Since frequent exposure to latex products can lead to increased sensitivity, healthcare professionals are at a higher risk of developing an allergy to latex proteins.
TYPES OF REACTIONS
Generally, people attribute any latex glove-related reaction as an “allergy,” but there are actually two types of latex reactions: Allergic contact dermatitis (Type IV hypersensitivity) and true latex allergy (Type I hypersensitivity).
TYPE IV HYPERSENSITIVITY: Allergic contact dermatitis is a reaction to the chemical additives used in the manufacture of latex gloves (OSAP, 2013). Symptoms take several hours to develop, and include swelling, redness, itching, and blistering/cracking of the skin. Patients and staff with allergic contact dermatitis require the use of vinyl gloves, as nitrile and neoprene gloves contain the same chemical additives found in natural rubber latex.
TYPE I HYPERSENSITIVITY: Conversely, true latex allergy is a reaction to the latex proteins. These proteins can infiltrate the body through skin and mucosa. If latex lightly powdered gloves are used, aerosolized latex proteins can also enter the respiratory system during gloving and ungloving (OSAP, 2013). Reactions can range from erythema and hives to the most severe reactions characterized by anaphylaxis. Patients and staff with true latex allergy require the use of non-latex gloves, such as nitrile, neoprene or vinyl.
Apart from dental healthcare workers, those “at risk” for allergic reactions are patients with asthma, a history of hay fever, or allergies to trees, grasses, animals, dust, molds and certain medications. Dentists can use this checklist to provide a latex-safe facility for patients and staff with possible or documented latex allergy:
- Screen all patients for latex allergy (e.g., obtain their health history)
- Be aware of some common predisposing conditions (e.g., spina bifida, urogenital anomalies, or allergies to avocados, kiwis, nuts, or bananas).
- Be familiar with the different types of hypersensitivity and the risks that these pose for patients and staff.
- Consider sources of latex other than gloves, including prophy cups, rubber dams, and orthodontic elastics.
- Provide an alternative treatment area free of materials containing latex.
- Remove all latex-containing products from the patient’s vicinity and adequately cover/isolate any latex-containing devices that cannot be removed from the treatment area.
- Give patients with latex allergy the first appointments of the day to minimize inadvertent exposure to airborne latex particles.
- Frequently clean all working areas contaminated with latex powder/dust.
- Frequently change ventilation filters and vacuum bags used in latex-contaminated areas.
- Have latex-free kits (e.g., dental treatment and emergency kits) available at all times.
- Be aware that allergic reactions can be provoked from indirect contact as well as direct. Hand hygiene is essential!
- Communicate latex allergy procedures (e.g., verbal instructions, written protocols, posted signs) to other personnel to prevent them from bringing latex-containing materials into the treatment area.
- If latex-related complications occur during or after the procedure, manage the reaction and seek emergency assistance as indicated.
Allergic Reactions to Dental Materials
Be prepared to react quickly to a patient’s adverse reaction
While in the dental chair, a patient can suddenly experience an adverse reaction to a drug, product, or material. Those most susceptible to allergic reactions are patients with asthma, a history of hay fever, or allergies to trees, grasses, animals, dust, molds and certain medications. Tailoring dental products to a patient’s health history is a proactive yet precautionary practice to minimize the occurrence of an adverse reaction. In the event that an adverse reaction does occur, recognizing the symptoms and reacting quickly is critical.
MATERIALS: Latex is most commonly found in gloves. Other dental materials that contain latex include latex dams, gutta-percha, mixing bowls, orthodontic elastics, some suction tips, bite blocks, and amalgam carriers.
SYMPTOMS: Adverse reactions can be classified as allergic contact dermatitis (Type IV hypersensitivity) or true latex allergy (Type I hypersensitivity). Allergic contact dermatitis is a reaction to the chemical additives used in the manufacture of latex gloves (OSAP, 2013). Symptoms take several hours to develop, and include swelling, redness, itching, and blistering/cracking of the skin. Conversely, true latex allergy is a reaction to the latex proteins. These proteins can infiltrate the body through skin and mucosa. If latex lightly powdered gloves are used, aerosolized latex proteins can also enter the respiratory system during gloving and ungloving. Reactions can range from erythema and hives to the most severe reactions characterized by anaphylaxis.
PRECAUTIONS: Patients with true latex allergy (Type I hypersensitivity) require the use of non-latex gloves, such as nitrile, neoprene or vinyl. Patients with allergic contact dermatitis (Type IV hypersensitivity) require the use of vinyl gloves, as nitrile and neoprene gloves contain the same chemical additives found in natural rubber latex.
PROBLEM: LOCAL ANESTHETICS
MATERIALS: Allergic reactions are only caused by ester-type anesthetics, which are used for topical application rather than local injection. Ester-type anesthetics, such as procaine, propoxycaine and chloroprocaine, are more
commonly known by their brand names: Novocain, Ravocaine, Nesacaine and Hurricaine. Amide-type anesthetics, like lidocaine, mepivacaine and prilocaine, can cause reactions resembling allergic reactions, but the anesthesia itself is not a true allergen.
SYMPTOMS: Most patient-reported “allergic” reactions to local anesthetics — namely heightened anxiety and increased heart rate — are really sensitivities to epinephrine. Occasionally, patients might experience a toxicity reaction, which can be attributed to preservatives (methylparaben) or antioxidants (bisulfites) contained in the solution. A toxicity reaction is more common when the anesthetic is used plain (i.e., does not contain a vasoconstrictor), which prevents the anesthetic from leaving the anesthetized site too rapidly.
PRECAUTIONS: Anesthetic cartridges without a vasoconstrictor should be used for patients with epinephrine sensitivity, or when a patient has severe heart disease or recent myocardial infarction. Topical anesthetics should be used sparingly, as excessive amounts or contact with the oral section of the pharynx could intensify a reaction.
PROBLEM: COLOR DYE
MATERIALS: Color dyes are typically found in prophy pastes, mouthwashes, fluorides and colored gloves. Red and yellow dyes are the main types of dyes that cause allergic reactions. Red #40, Yellow #5 and Yellow #6 are types of artificial dyes, whereas annatto is a natural coloring substance that comes from seeds of the annatto tree (Yacono, 2011).
SYMPTOMS: Skin irritations, such as eczema or hives, are common symptoms that develop after the ingestion of a particular dye. In rare cases, certain dies can cause anaphylactic shock. The effects of color dyes on behavioral issues—especially in children—are currently being researched.
PRECAUTIONS: Dye-free prophy pastes, fluorides, rinses, etc. are available alternatives and should be used with patients reporting a dye allergy, or as an option for pediatric patients.
A Comprehensive Look at Dental Unit Waterlines
Eliminating the risk of contamination requires going beyond the status quo
In 2011, the dental industry received international attention when an 82 year old Italian woman died from a case of Legionnaire’s disease she contracted during dental treatment—its source traced to contaminated water from dental unit waterline tubing.
A Perfect Storm for Biofilm
Bacterial biofilm is virtually universal in untreated dental unit waterlines and can begin forming in a new dental unit within days. Although there has only been a handful of reported cases of dental waterline contamination since 1963, many microorganisms of concern have been isolated from dental unit water, namely Pseudomonas species, non-tuberculosis mycobacteria, and Legionella, the causative agent of Legionnaires’ disease. Legionella poses a particular threat because it can be transmitted by inhaling aerosols or aspirating water contaminated with the bacteria. Because of their narrow tubing (1/8” to 1/16”), dental waterlines provide particularly well-suited conditions for biofilm–a community of bacteria and other microbes that adhere to surfaces and form a protective slime layer. Low water pressure, low flow rates, and frequent periods of stagnation also encourage any bacteria introduced from municipal water to accumulate within the tubing.
Anomalies of Waterline Testing
According to the American Dental Association (ADA) Council on Scientific Affairs’ 1999 report to the profession on dental unit waterlines, evaluating water quality before a treatment protocol is implemented is controversial. Because the scientific literature suggests that all units are highly contaminated, pre-testing to confirm contamination is of questionable value. However, testing water quality after initiation of a treatment regimen ascertains whether a waterline product or protocol achieves the desired outcome. Monitoring water quality according to an established schedule can help identify problems in performance or compliance and provide documentation of water quality.
Waterline Monitoring Recommendations
Both in-office monitoring devices and commercial testing services are available. Dentists should consult with the manufacturer of their dental unit or water delivery system to determine the best method for maintaining acceptable water quality (i.e.,
Waterline Treatment Options
FLUSHING: Mechanical flushing alone does little to control contamination in waterlines. Although it can temporarily reduce the number of microbes in the water delivered to patients by clearing away many of the free-floating organisms in the waterline, biofilm bacteria continually break free and recontaminate dental unit water during the course of clinical treatment. Flushing for several minutes between patients, however, may be valuable in removing contaminants that can enter the water system during patient treatment.
SELF-CONTAINED WATER SYSTEMS: Also referred to as independent water systems or reservoirs, these isolate the dental unit from the municipal water supplies, instead providing water or treatment solution from reservoirs filled and maintained by office staff. They allow the practice to control the quality of water that is used in the unit.
CHEMICAL DISINFECTANTS: A number of chemicals are reported to inactivate or prevent biofilm, whether through periodic (intermittent or “shock” treatment) or continuous presence in the waterline. Periodic disinfection involves purging the waterlines, adding a chemical to the water reservoir, filling the lines for the recommended time period, and flushing. Continuous chemical treatment refers to waterline treatment via an irrigant/coolant solution or the use of automated metering devices. Metering devices release low levels of chemical germicide into the treatment water to control biofilm to lower bacterial counts in the water. Some products may require both intermittent and continuous line treatments to maintain water quality.
No matter the treatment option you implement in your practice, strict compliance with the recommended treatment regimen is the key to consistent water quality.