Are Your Dentist’s Tools Clean?

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It is extremely unlikely that you get HIV from a dentist appointment.

Fox6Now.com: Tomah VA dentist accused of using improperly cleaned tools resigns

I shouldn’t read news as I always have something to say about them. This news above reminded me about working in the UK and how the instruments were cleaned there.

This Thomas VA dentist is not the only dentist that is underperforming in the instrument cleaning. There are dentists who have read this news and have wiped sweat from their foreheads and thanked their lucky stars it wasn’t their name on the headlines. Honestly!

Let me tell you how things were done in six of the practices I used to work in the UK. I will first go through the correct way of cleaning the instruments.

This I How It Should Be Done

1. Disinfect the contaminated instruments preferably in a washer disinfector like Miele Dental Disinfector

With this washer disinfector the cleaning job is half done. You just put used instruments within 4 hours of using them to the washing cycle and you get disinfected instruments in less than an hour (no need to soak them in anything prior the cycle).

No scrubbing is needed which will minimise the accidents of nurses cutting themselves.

2. Dry the instruments thoroughly. Use pressurised air on all the hard-to-reach areas like matrix retainers, sonic scaler tips, forceps.

3. Place the instruments that  don’t need to be sterile on the metallic tray to be autoclaved. Put the instruments that need to be sterile in pouches and close the pouches.

4. Put all the instruments in an up-to-date vacuum autoclave and run the cycle. Once they are cooked, put them in cupboards or drawers to be picked to the surgeries.

Simple and pathogen-free tools.

This Is How It Should Not Be Done

None of the surgeries I worked at in the UK had washer disinfector. Instead there was a dish brush and Hibiscrub. Yes, you read it correctly. Hibiscrub was used like washing up liquid on dish brush and the instruments were washed over a sink in the surgery. But this was done only up until health and safety regulations stated that using dish brush was a health hazard – there was too big risk of an injury from sharp instruments.

Once the instruments were brushed with Hibiscrub and rinsed with water, the instruments were placed on metallic trays (no drying) and put in the Instaclave, the simplest of the simplest model (non-vacuum). If there were surgical instruments, they were either put on the pouches and put on trays without closing the pouch. The pouch was closed after the cycle in the Instaclave. Sometimes the surgical instruments were put on the trays without pouches and once they had gone through the cycle, the nurse put them in the pouches that were taken straight from the package. This of course meant that the pouch was non-sterile as it had not gone through the cycle in the autoclave. Non-sterile pouch equals non-sterile instrument – no matter if the instrument has gone through the cycle.

So needless to say that many things went wrong. And let me clarify that all the above was done in the surgery. Every surgery had their own autoclave – just about five feet away from the patient.

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This was the typical setup in the dental surgery in the UK for cleaning tools used on patient

The Question: Did I Do It Too?

Well, as much as I think that you live by the rules of the country you are in, I did not follow this questionable way of cleaning instruments. I did inventory on surgery’s storage room and found a container with a lid. I asked the practice manager to order me instrument disinfection liquid. I had to do some convincing before the liquid was ordered – understandably of course as no-one else was using one. So why should I?

So all my instruments were brushed with dish brush under running water and then placed into this container which had disinfection liquid in it. The instruments were kept in there for the recommended time, rinsed with water, dried and then put in the Instaclave.

Not perfect, but enough for me to have a clean conscience.


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Yet Another Anti-Patient

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How on earth did I not remember this type of Anti-Patient? I guess it is all coming slowly (but surely) back to me after returning to work.

Before you read any further, it might be good idea to read my post Anti-Patient so you know what I am on about.

Anti-Local Anesthesia

Now, this type of patient is not so uncommon in the dental chair. Let me tell you about the two of the most typical situations I face.

Patient Case I

I am about to start the scaling and root planing and I can tell from the looks of the gum that it is going to be painful. I offer local anesthesia (LA) but the patient declines by saying:

“I once had such a bad experience with LA that I have not taken any since..”

Or

“Oh, I never take any LA, not even when I have a filling done.”

I explain that it will most likely hurt but the patient does not change his mind. Not even when I explain we could use topical LA (I use Oraqix) which would not require needles.

So I begin the treatment. The sonic scaler goes relatively well but when I begin to scale those deep pockets the patient is jumpy (as if somebody was poking his limbs with a needle), turns his head suddenly (exaggeratingly) and is kinda slowly sliding towards my lap as he’s pushing from the handles of the chair.

After I have nearly injured my own finger and patient’s lips for the third time because of the unpredictable motions and after I have three times asked patient not to move his head, I stop the scaling and tell the patient that I won’t be able to carry on unless he keeps the head absolutely still. Because it’s not safe. I offer the LA again and usually at this point they agree.

Patient Case II

The patient (who also just declined LA) keeps still throughout the treatment (scaling) and says she’s fine when I ask her if she’s ok  (multiple times). So naturally I carry on to finish the treatment.

Once the patient gets up from the chair she does not look happy and says

“It hurt a lot.”

Or

“Oh I hate having this done.”

Or

“It’s never hurt before.”

Soooo annoying! Did I or did I not offer you LA? Of course it hurts if you decline LA when it is recommended. And why would you say you are fine when you are not?

What is the most annoying in all this is that she will go and tell ten of her mates how horrible experience it is to have the teeth cleaned. Simple marketing rule – bad experiences you tell to ten people, good experiences to one. So unfair!

Ever Seen a Patient with an Implant? Read This!

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Today I saw a patient who had had an implant done to replace upper right first molar. The implant treatment was finished a year ago in another practice.

Since then the patient had seen hygienist twice in my practice. The implant crown itself looked immaculate but the gum was very red and puffy and it bled heavily after probing.

I knew what to ask next and I even knew the patient’s reply to this.

“Were you told how to clean the implant at home?”

“No I wasn’t” replied the patient with is-it-supposed-to-be-cleaned-expression on his face.

This happens too often. Almost every time I see a patient who has recently had an implant done.

Note for all the dental professionals who make the implant treatment’s final stages and do not give oral hygiene instructions (OHI) for the patient:

You should always tell and show how the patient can clean these costly pieces of metal and porcelain. It is your responsibility as a dental professional and the paying patient’s right!

Can you give me any other excuse for not giving OHI than the fact that you are too busy making money and forgetting the basics? I believe you cannot.

And you hygienists who see patients with implants:

  1. Always check how the patient is cleaning them. More so if the gum around the implant is either bleeding or there is plaque around it
  2. Advice if necessary and show in their mouth how it is done
  3. Check if the patient understood your instructions by asking them to show they can do it. Teach them if they struggle
  4. Check on a follow-up visit that the gum has healed. If not, refer to a dentist

Why Is It So Important?

With the implants it is vital that there is no bleeding in the surrounding gum. They will get an implant’s equivalent to gingivitis – peri-implant mucositis which can lead to the peri-implantitis (same as periodontitis with teeth) very rapidly. The worst case scenario is that the implant will lose its integration to the bone which could have been easily prevented.

The patient I saw today left home with instructions on how to look after his implant. And I will see him for a follow-up visit to make sure the gum has healed (can you see the shining halo around my head?).

Honestly, it’s not that hard to do your job properly so shape up please!


Here‘s further reading on the subject.