Considerations for Processing Dental Instruments
Trays Vs. Cassettes
Catherine Pawloski, RDH; Marie T. Fluent, DDS
There are two main ways to process and transport dental instruments—process loose instruments in pouches, place onto trays, and deliver to and from the operatory; or secure instruments in a locked sterilization cassette to be packaged and processed, and transport to the operatory and back to the sterilization area. The decision to use trays versus cassettes involves a number of factors. Compliance with infection control guidelines and regulations, and safety of dental healthcare personnel (DHCP) is paramount. Other considerations include productivity and efficiency, packaging integrity, professional appearance, and cost.
Infection Control Guidelines
Prior to the investment of any infection prevention and safety product, dental personnel should first and foremost consider compliance with guidelines and regulations. The Centers for Disease Control and Prevention (CDC) Guidelines for Infection Control in Dental Health-Care Settings–2003 set the standard for the infection control and safety practices used by dental professionals in the United States. In 2016, the CDC issued Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care, which reinforces the existing guidelines, adds new recommendations, and provides checklists to help dental personnel comply with recommended practices.
The CDC provides many recommendations for infection prevention and safety, and OSHA mandates many of these recommendations to ensure the safety of dental healthcare personnel. Neither entity mandates the use of trays or cassettes, however, both agencies recommend minimal handling of loose contaminated instruments.
Staff Training and Safety
Proper training of dental personnel who process instruments is important for either method. The CDC recommends, and OSHA mandates, that personnel are trained for their specific job duties upon hire, annually, and whenever job duties that pose an occupational risk are changed. General training requirements include ways to reduce risk of contracting an illness or injury on the job, policies and procedures for reporting injuries, and obtaining medical care. In addition, training should also include reporting any medical conditions that may make you more susceptible to injury or infection (or that may create a risk of transmission to other staff or patients).
It is necessary to train DHCP on all processing steps, including instrument transport, cleaning, inspection, packaging, sterilization, sterilization monitoring, and storage. DHCP must also be trained to follow all manufacturer instructions for use (IFU) for all products and equipment used for cleaning, packaging, and sterilization. Policies, procedures, and manufacturer reprocessing and maintenance instructions for reusable instruments and dental devices must be available in or near the reprocessing areas to ensure that all equipment is used and working correctly.
When processing loose instruments, DHCP handle contaminated instruments more often than when using cassettes. This poses more vulnerability, as there is an increased risk for sharps injury and/or exposure to bloodborne pathogens. In contrast, cassettes minimize the handling of loose instruments in all phases of reprocessing. Regardless of the system that is utilized, it is recommended for DHCP to wear heavy-duty utility gloves when handling contaminated instruments.
Efficiency and Productivity
When loose instruments are placed into several different pouches, organization and storage can be compromised. Dental personnel must sift through each pouch to observe whether it is indeed the correct set-up, and whether all instruments are present. As pouches are emptied on to a tray, the contents spill in random order and may even find their way to the floor.
In contrast, sterilization cassettes include silicone rails, which ensure that instruments are aligned and in sequence. As the cassette is opened in the operatory, instruments remain in place, arranged in order of use. After the procedure, DHCP return the various instruments to their correct location and they remain in place throughout reprocessing.
Instrument Preservation and Packaging Integrity
When processing loose instruments, they can move about freely, causing damage to their tips or other items in the load. It is common for mouth mirrors to become scratched while being cleaned in an ultrasonic unit, and for the tips of explorers and probes to become damaged, distorted, or bent. However, in cassettes, instruments are held securely in place, reducing the chance of damage or loss of instruments.
Pouches with a greater number of loose instruments and those with sharp tips will enhance the likelihood of a pouch perforation. When this happens, the contents of the pouch are no longer considered sterile and the instruments must be removed and reprocessed, presenting a safety concern. In contrast, wrapped or pouched cassettes are rarely, if ever, compromised as sharp tips are securely contained within.
Pouches and cassettes may also be compromised due to moisture. Dental personnel must keep all instrument packages clean and stored once dry to ensure sterility.
Additional Considerations
Cassettes may hold unit dose supplies that can be added after cleaning, rinsing, and drying to eliminate the need to touch cabinets, drawers, and containers during treatment.
Both pouches and cassettes are available in a multitude of sizes to accommodate all types of instrument set-ups. When using cassettes, it is important to ensure that the cassette size is compatible with the size of the automated cleaner and heat sterilizer.
As dental personnel compare delivery systems, it may appear that the use of pouched instruments on trays may be more cost-effective than cassettes. It is true that there is an initial investment with cassette usage. However, DHCP should weigh the cost versus benefit and timesavings during instrument processing (in addition to safety, efficiency, and productivity). Cassette usage may also provide a more professional and up-to-date appearance and improve patient confidence.
Whether processing loose instruments in pouches, or secured in cassettes, help is available for all phases of instrument processing through resources from the CDC, OSHA, state, and the Organization for Safety, Asepsis and Prevention (OSAP, www.osap.org) to deliver the safest dental visit possible.
Conclusion
Delivery systems consisting of loose instruments on trays or instruments in cassettes are both widely used in the United States. No matter which system is chosen, compliance with infection control guidelines and regulations and safety of staff and patients should remain top priority.
Disclosures
Both authors received an honorarium from Hu-Friedy for writing this article.
About the Authors
Catherine L. Pawloski, RDH, currently works in clinical practice in Michigan. She has written articles relating to the topics of infection control in the dental office and OSHA/CDC guidelines.
Marie T. Fluent, DDS, practiced general dentistry for 25 years. She is currently an infection control consultant, speaker, and an educational consultant for OSAP, and has written extensively about infection control, OSHA compliance, and antibiotic stewardship in dentistry.
