Surface Disinfectants for the Dental Office

A dental assistant had a question about disinfectants used to clean operatories between patients.

The OSHA guidelines state:

1910.1030(d)(4)(ii) All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.

1910.1030(d)(4)(ii)(A) Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures; immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials; and at the end of the work shift if the surface may have become contaminated since the last cleaning.

However, this still didn't answer the question of what an "appropriate disinfectant" is.

After searching for research on PubMed, DARE and the ADA website, I was only able to find one citation: 

Boyce R, Mull J. Complying with the Occupational Safety and Health Administration: guidelines for the dental office. Dent Clin North Am. 2008 Jul;52(3):653-68, PMID: 18501741 on PubMed.gov

Under the Housekeeping Section of this article it states, "All potentially contaminated work surfaces must be cleaned with an appropriate cleanser before and after concluding patient visits." This statement is in accord with the OSHA guidelines. However, this article also mentions that the Environmental Protection Agency (EPA) web site lists approved cleansers that are registered tuberculocides and known to eradicate HBV/HIV.

Now, I was on the hunt for this elusive list of appropriate cleansers... The next step was to search the EPA web site for their standards at http://www.epa.gov

Typing "registered disinfectants" into their search queue reulted in 3,430 results. By scrolling through these results and clicking on results that seemed relevant, I finally found this list after almost four hours of searching for what seemed to be a simple question. This was a VERY time consuming search.

The list of selected registered EPA surface disinfectants is found online at http://www.epa.gov/oppad001/chemregindex.htm

List E: is a PDF published in January of 2009 of EPA’s Registered Antimicrobial Products Effective Against Mycobacterium tuberculosis Human HIV-1 and Hepatitis B Virus

I compared this list to a dental catalog and was surprised to see that from a long list of disinfectants, only a handful were EPA approved. Is what you are using an appropriate disinfectant? Check the list and find out!

EPA’s Registered Antimicrobial Products Effective Against Mycobacterium tuberculosis Human HIV-1 and Hepatitis B Virus

The ebdLibrary is in the process of being developed to answer these types of questions for practitioners. This resource will provide valuable tools and resources to dentists and their staff so that patient care and office procedures are compliant with current information and can be easily incorporated into everyday decision-making.


Infection Control Today Comparison of Commonly Used Surface Disinfectants

Center for Disease Control (CDC) 2008 EB Guidelines for Disinfection and Sterilization

CDC Table of Methods of Sterilization and Disinfection

CDC Guideline of Disinfection and Sterilization in Healthcare Facilities Nov 2008

CDC Recommended Infection Control Practices for Dentistry




Evaluating the Evidence 

When critical summaries can not be found that evaluate current research for you, it is necessary to complete the evaluation step on your own.

There are numerous critical appraisal forms that can be used for this purpose. CASP (The Critical Appraisal Skills Programme), CONSORT/PRISMA, and The User's Guides to the Medical Literature are just a few resources that provide critical appraisal forms.

CASP critical appraisal tools can be found at http://www.phru.nhs.uk/pages/phd/resources.htm

CONSORT stands for Consolidated Standards of Reporting Trials. CONSORT 2010 It is a 25 item checklist that was just updated this year, nullifying the 2001 CONSORT Statement version.  It was established to help authors improve reporting randomized controlled trials. It is available for free download at http://www.consort-statement.org/consort-statement/overview0/

The former QUOROM statement is now PRISMA which stands for Preferred Reporting Items for Systematic Reviews and Meta-Analyses. It can be used as a critical appraisal forms for systematic reviews and meta-analysis. The PRISMA statement consists of a 27-item checklist and a four-phase flow diagram. This form parallels the CONSORT 2010 form and is available at http://www.prisma-statement.org/

User's Guides to the Medical Literature is a series of articles that were originally published in the Journal of American Medical Association, then in a book. They are available online at http://jamaevidence.com

The ebdLibrary at www.edbLibrary.com uses critical appraisal forms to evaluate research that doesn't already have critical summaries published.



Finding the Evidence to answer Dental Questions

After you have written your PICO clinical question you are ready to start your quest to find the answers.

Where do you begin? There are dozens of resources you can choose from. This entry will highlight a few online resources that are helpful.

PubMed is the free version of the biomedical database MEDLINE. It has a Clinical Queries feature which filters citations for types of evidence. Searching for Systematic reviews or randomized controlled trials is simplified using this feature. Results from a search can be further filtered by Language, Age, etc. Citations that answer a question can be saved to a clipboard. Full-text articles can be purchased online through some of the publishers.

The ADA has a Center for Evidence-based Dentistry which provides a listing of Systematic Reviews that answer oral health questions. Critical Summaries are available for a number of these Systematic Reviews. This database can be searched with one key word or by topic. The citations link to the PubMed abstract or to the ADA critical summary.

The Database of Abstracts of Reviews of Effects contains 15,000 abstracts of systematic reviews and includes the critical summaries of these reviews as well as details of all Cochrane reviews and protocols.

The Cochrane Collaboration houses systematic reviews published and updated by the Cochrane Groups, including the Cochrane Oral Health Group. Here one can read all of the abstracts and protocols for free.

Additional resources are The Center for Disease Control, The Environmental Protection Agency, The National Institutes of Health and other government agencies that house information pertinent to dentistry. Most specialties also have websites that provide resources to practitioners that are helpful. For example, The American Academy of Pediatric Dentistry has links to guidelines and information for Pediatric Dentistry.

The ebdLibrary http://www.ebdlibrary.com searches all of these sites for you to find the research to answer specific clinical questions. This simplifies the process by eliminating the need to search multiple online resources to find evidence-based answers to clinical questions.




PICO-Asking clinical questions

PICO is the evidence-based way of describing a focused clinical question. It involves four parts that make up the acronym PICO.

P- describes a patient or problem. For a patient with Temporomandibular Joint Dysfunction Syndrome

I- identifies the intervention. will Botox

C- describes the comparision. as compared to a mouthguard

O- outlines the outcomes that you hope to achieve for that patient or problem. alleviate pain, joint clicking, and muscle tenderness?

The PICO question would then be phrased as:

For a patient with Temporomandibular Joint Dysfunction Syndrome will Botox as compared to a mouthguard alleviate pain, joint clicking, and muscle tenderness?


PICO is the information map to help you find the answer to your clinical question. It provides a format to identify key terminology. This helps find the research that studies the outcomes that are relevant to your clinical question.

Searching online biomedical databases for evidence to answer a clinical question can be like swimming the English Channel. This undaunting task can be simplified by combining terms from the PICO question which helps to narrow the amount of literature to a manageable size.  For example, using PubMed and typing the term TMJ yields 19, 673 citations. Using the MeSH term Temporomandibular Joint Dysfunction Syndrome (Medical Subject Heading- which a glossary of terms and describes how these terms are indexed in Medline) cuts this content to 4,494 which is still an insurmountable amount of research.

For this particular clinical question, it would be nice to find a study that compared a standard treatment (mouthguards) with the new therapy of Botox injections. To do this it is necessary to utilize Boolean Operators in Medline or PubMed (the free version of Medline)

By using the Boolean Operators (AND, OR, NOT) to combine the PICO search terms-


Unfortunately this search does not yield any citations. Therefore, by changing the AND to an OR


Temporomandibular Joint Dysfunction Syndrome AND (Botox OR Mouthguards) yields a very manageable 6 citations.

The Outcomes portion of the PICO question are utilized when reading the abstracts and making the article selection to choose research that measured the outcomes you are hoping to answer/achieve in treating the patient or solving the problem.

New evidence-based filters such as PubMed's Clinical Queries simplify the searching process and seem to eliminate the need for PICO, but I feel that it is still a critical step in helping the clinican focus the chief concern into a concise question that can be efficiently answered.

PICO questions are written for each critically appraised topic available this Fall on www. edbLibrary.com. This is one key step that will be completed for subscribers and will help clinicians evaluate if the question being asked is the same question they need an answer for.




What is Evidence-Based Decision Making and Evidence-Based Dentistry?

The concept of the evidence-based process was first introduced by a group led by Gordon Guyatt at McMaster University in Ontario, Canada. The Evidence-Based Medicine Working Group published their first article in 1992 to describe a new paradigm for medical education that was designed to overcome the deficiencies of traditional education by incorporating current research into education and practice. (JAMA 1992; 268:2420-5)

David Sackett defines Evidence-Based Medicine as the "integration of best research evidence with clinical expertise and patient values." Using the evidence-based process requires the development of five necessary skills.

Skill 1: Formulate foreground/PICO questions: The ability to convert information needs or problems into clinical questions so that they can be answered.

Skill 2: Conduct a computerized search: The ability to conduct a computerized search with maximum efficiency for finding the best external evidence with which to answer the questions.

Skill 3: Critically appraise the evidence: The ability to critically appraise the evidence for its validity and usefulness (clinical applicability)

Skill 4: Apply the results to your patient or practice: The ability to apply the results of the appraisal of evidence in clinical practice.

Skill 5: Evaluate the process and your performance: The ability to evaluate the outcomes of the process and your performance through self-evaluation. (Sackett et. al. Evidence-Based Medicine: How to Practice & Teach EBM. 2nd ed. London, England: Churchill Livingstone; 2000)

Evidence-Based Decision Making is defined as the formalized process of using the skills for identifying, searching for and interpreting the results of the best scientific evidence which is then considered in conjunction with the clinican's experience and judgment, the patient's preferences and values, and the clinical or patient circumstances when making patient care decisions. (Forrest, Miller, Overman, Newman. Evidence-Based Decision Making: A Translational Guide for Dental Professionals)

The American Dental Association has defined Evidence-Based Dentistry as "an approach to oral health care that requires the judicious integration of systmatic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and histroy, with the dentist's clinical expertise and the patient's treatment needs and preferences." (ADA,  http://ebd.ada.org/About.aspx)

There are now thousands of articles and textbooks that teach practitioners how to use this process. There are also evidence-based journals and resources for multiple disciplines including, nursing, law, medicine and dentistry. Several online resources are available to simplify this evidence-based process for dentistry. However, most of these resources still require an understanding of research methods and the time and skills to access, read and appraise the literature.

The evidence-based dental library will follow the medical model of critically appraised topics. It uses the evidence-based process to answer pertinent dental questions. These are made available online to subscribers at www.ebdlibrary.com