Are you doing the right thing? Asepsis is the answer. Part 2

By: Dr. Ali Mehdi (BSc, BDS, Fellowship | Oral and Maxillofacial Surgery)

As a continuation to my previous post,  I will discuss exact recommendations on how to prepare your operatories for implant surgeries. While the Clean Technique is routinely practiced in modern dental offices (this includes hand washing, the use of non-sterile gloves and masks, and a strict sterilization process for instruments), the aseptic technique should be the standard for any surgical dental implant procedure as a protection to the patient, surgical team, and yourself.

The Joint Commission outlines four aspects to the aseptic technique:

1.     Equipment & Patient Preparation;
2.     Barriers;
3.     Environmental Controls;
4.     Contact to Contact Guidelines.

1. Equipment and patient preparation

All counters, chairs, monitors, and working spaces should be thoroughly wiped down with CaviWipes, CaviCide, or any other cleaning supplies you may have in your office. Sterile drapes are to be placed on and fastened to countertops, especially under the implant machine, implant drill kit, and surgical cassette. Preparation of the implant machine and surgical kit should be done with sterile gloves on. Sterile tubing is to be placed on the suction hose and on the handle of the drill. Although the room need not be sterile, it certainly should be clean and free of dust and visible debris.

Patient Preparation: Extra oral preparation – the nurse uses a sterile, chlorhexidine-soaked gauze (instead of betadine since it may tattoo/pigment the skin), to wipe circumorally around the patient’s mouth, working outwards from the patient’s lips to their chin and nostrils to reduce the transmission of microorganisms from the extra oral tissues to the operating site this is done prior to applying surgical sterile drapes on the patient which isolates the perioral field.

2. Barriers

This antiseptic surgical hand scrub technique is applied to the hands, subungual areas and forearms, inhibiting the rapid rebound growth of microorganisms. The technique should be carried out with the hands held directly above directly above the elbows (to allow any microbes to drain away from the fingertips), working down each arm covering all surfaces from fingertip to elbow, never working back up the arm.

Gowning and Gloving – the surgical nurse must surgically gown and don sterile gloves (as does the clinician) ready to begin preparing a sterile field. The nurse is classed as sterile from the shoulder to waist on their front.

Zoning, draping and handling – the nurse must drape all surfaces intended for use within the procedure with a radiation sterilized disposable drape and must only handle sterile items and places a sterile drape onto the patient to prevent microbial contamination from the patients clothing to the sterile field.

Further to this, the clinician and the 1st assistant should not have any hand jewelry or watches on their wrists.  I understand we all love our Swiss chronometers, but we do take them home with ourselves as well and during a day’s work, they can harbor a plethora of microbes that we do not want near our loved ones or ourselves.

3. Environmental Controls

Doors should be kept closed, traffic in and out of the operatory should be minimized, and only necessary personnel present during the surgical procedure.

In an ideal setting, it should only be the surgeon, the 1st assistant and the second assistant (duties elaborated below)

4. Contact to Contact Guidelines

Only sterile to sterile contact is allowed. The chairside assistant and doctor will rely on a secondary assistant to open non-sterile items, record operative notes, etc. The secondary assistant will not touch any sterile field, instruments or equipment.

Nurse 2 Duties: The circulatory, non-sterile or dirty dental nurse duties:

  • Assists the scrub nurse in setting up the sterile field.
  • Doesn’t contaminate by handling any sterile items.
  • Wears a mask and a surgical hat to prevent contamination of the sterile field.
  • Ensure that all items required for the procedure are ready.
  • Doesn’t reach over or come within 30cm of sterile field.
  • Removes all items which are not to be used in the procedure away and wipe down all work top surfaces and walls ‘up to 1.21metres or 48inches from the floor’ (miller.m.ed. 2008. P156) with an antimicrobial wipe. Must ensure the floor is cleaned thoroughly before the procedure.
  • Opens all pre-wrapped sterile instruments (which have been processed in a vacuum autoclave cycle and aseptically stored prior to the procedure), surgical and drapes kits, ready for the sterile nurse to receive.
  • Carries out the preoperative procedure, ensuring they have taken prophylactic antibiotics and anti-inflammatory medication and providing the patient with a surgical hat to prevent pathogen contamination from the hair and eye protection from aerosol.

Other measures that can be taken during the procedure:

Implants and bone graft material should be opened only once the clinician is ready for them to minimize airborne contamination or damage and hence wastage if they are not used in the treatment episode.

Lab work (including surgical stents) must be decontaminated appropriately prior to use within the patient’s mouth.

Stay tuned for my next series of blogs, which will help increase the predictable success rate for your implant practice.

 

Dr. Ali Mehdi
BSc, BDS, Fellowship (Oral and Maxillofacial Surgery)
Certified in, Oral implantology, Soft tissue handling and cosmetic repairs, ATLS, 8+ years Implant career

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