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RESEARCH

The effect of long-term disinfection


on clinical contact surfaces
Charles John Palenik, MS, PhD, MBA

isinfection is the destruc-

D tion by physical or chemical


means of microorganisms,
including pathogens. Disin-
AB STRACT
Background. The author measured the effect
long-term disinfection had on common types of

✷✷
J
A D
A

N
CON
fection is less lethal than is sterili-

IO
dental office environmental surfaces.

T
zation because it destroys most rec-

A
N

I
C
Methods. The author tested nine common A
U
IN
ED
U

ognized pathogenic microorganisms RT 2


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dental surfaces and six spray disinfectants, as I C LE


but not necessarily all microbial well as a tap water control. The author used the “spray-
forms (for example, bacterial wipe-spray” method with paper towels to disinfect the surfaces.
spores).1 Each surface was disinfected 1,920 times, which was an estimate of
An estimated 1.7 million health the number of cleanings per year. After every 100 disinfections, the
care–associated infections occur an- author conducted blood removal testing of the surface, which moni-
nually in the United States, result- tored residual blood and disinfectant cleaning ability.
ing in 99,000 deaths.2 The major Results. The surface that was most difficult to clean was tex-
source of the involved pathogens is tured vinyl, followed by smooth vinyl, enameled metal, service line
patients’ endogenous flora; however, rubber hosing and brushed aluminum. Diluted bleach affected sur-
an estimated 20 to 40 percent of faces the most, which resulted in higher blood removal scores.
health care–associated infections Conclusions. When compared with the control, Birex SE had
appear to be cross infections in- equal or better cleaning scores across time, which might indicate
volving the hands of health care that its use caused little change in the integrity of the surfaces.
workers. Worker hand contami- The results for the other disinfectants varied.
nation could result either directly Clinical Implications. Disinfectants should have good antimi-
from patient contact or indirectly crobial activity and minimal negative impact on the integrity of the
from touching contaminated envi- surfaces being disinfected. Effective disinfection is highly depen-
ronmental surfaces.3,4 dent on efficient cleaning (removal of the bioburden present).
Results from two recent studies Key Words. Disinfection; environmental asepsis; surface
show the role hospital environments cleaning; surface integrity.
play in methicillin-resistant Staphy- JADA 2012;143(5):472-477.
lococcus aureus (MRSA) transmis-

Dr. Palenik was the director, Infection Control Research and Services, Department of Oral Biology, Indiana University School of Dentistry, Indianapolis,
when this article was written. He now is the director, Scientific Affairs and Research, Organization for Safety, Asepsis and Prevention, Annapolis, Md.
Address reprint requests to Dr. Palenik at 5868 E. 71st St., Indianapolis, Ind. 46220, e-mail cpalenik@osap.org.

472 JADA 143(5) http://jada.ada.org May 2012


Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH

sion and support the need for proper surface fectant wipe or towelette that is discarded, and
cleaning and disinfection.5,6 Health care workers the surface is wiped again with a new wipe or
are a clinically relevant source of cross infection. towelette.1,8,9
One of the studies involved 40 patients with Although no perfect disinfectant exists, there
MRSA who were admitted to a Veterans Affairs are a number of desirable characteristics for
hospital.6 The researchers found that hand con- such products.8-11 Use of the disinfectant should
tamination among health care workers was result in the death of a wide variety of patho-
equally likely after contact with commonly genic microorganisms without causing the
examined skin sites or with frequently touched emergence of resistant forms. Disinfecting
environmental surfaces in patient rooms (40 action should be efficient and effective, even in
percent versus 45 percent, respectively). the presence of organic material. Exposure to
Dental instruments, devices and equipment the disinfectant should not harm humans or the
fall into one of three categories—critical, semi- environment. Modest cost, a pleasant odor and
critical or noncritical—depending on the risk of an extended shelf life also are beneficial.
development of an infection associated with A disinfectant must have good antimicrobial
their intended use. Critical items penetrate soft activity and at the same time have minimal
tissue or bone, have the highest risk of trans- negative effects on the integrity of the surfaces
mitting infection and require sterilization by being disinfected. A disinfectant that causes the
means of heat. Semicritical items touch mucous surface to degrade could make the surface not
membranes or nonintact skin and have a lower only esthetically unpleasing but also harder to
risk of transmitting infection. Most semicritical clean and disinfect across time. There is a
items used in dentistry are heat tolerant and paucity of information in the literature con-
should be sterilized before reuse.1,7 cerning the outcome of repeated contact be-
Noncritical items include clinical contact sur- tween disinfectants and surfaces. Therefore, I
faces, such as bracket tables, countertops and conducted a study designed to measure the
radiography equipment. Noncritical items have effect long-term disinfection had on common
the lowest risk of transmitting infection, be- types of dental office environmental surfaces.
cause they contact only intact skin, which can
serve as an effective barrier to microorganisms. METHODS
The U.S. Environmental Protection Agency I tested nine common dental surfaces and six
(EPA) registers disinfectants used on noncritical spray disinfectants, as well as a tap water con-
surfaces. In the absence of blood, health care trol. I used the spray-wipe-spray method with
workers can disinfect surfaces using an EPA- paper towels to disinfect the surfaces. I con-
registered hospital-level disinfectant that does ducted blood removal testing of the surfaces to
not have a tuberculocidal claim. When blood is measure the disinfectants’ cleaning ability.
visible, health care workers need to use an Test surfaces. The nine types of surfaces I
intermediate-level disinfectant, which is one chose as test samples were smooth vinyl; tex-
with a tuberculocidal claim. Because it is often tured vinyl; brushed aluminum; smooth stainless
difficult to see blood, the agent of choice for clin- steel; laminated, heat-resistant thermosetting
ical contact surfaces is an intermediate-level plastic (Formica, Formica Group, Cincinnati);
disinfectant.1,8,9 service line rubber hosing; high-impact plastic;
Proper disinfection is a two-part process: acrylic resin sheets (Plexiglas, Altuglas Interna-
cleaning followed by disinfection. A single agent tional, Bristol, Pa.); and enameled metal. Each
usually can accomplish both tasks. Cleaning surface-disinfectant pairing had 10 samples,
reduces the number of contaminating microor- each being a 10-centimeter square at least 20
ganisms, the amount of bioburden (such as millimeters thick, except for the service line
blood and saliva) and other adherent materials. rubber hosing, which was 15 cm long.
Disinfectants with good detergent action are Disinfectants. The six disinfectants I chose
preferable. When organic materials are present were Birex SE Concentrate (Biotrol, Earth City,
and not removed, they can insulate microorgan- Mo.), CaviCide spray (Metrex, Orange, Calif.),
isms and decrease disinfectant activity.1,8,10 regular bleach (Clorox, Oakland, Calif.) diluted
There are two approaches to cleaning fol- 1:10 with tap water, DisCide ULTRA Disin-
lowed by disinfection. In the “spray-wipe-spray” fecting Spray (Palmero Health Care, Stratford,
method, the surface is sprayed with a disinfec-
tant, wiped with a paper towel and sprayed ABBREVIATION KEY. EPA: U.S. Environmental Pro-
with disinfectant again. In the “wipe-discard- tection Agency. MRSA: Methicillin-resistant
wipe” method, the surface is wiped with a disin- Staphylococcus aureus.

JADA 143(5) http://jada.ada.org May 2012 473


Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH

TABLE 1

Disinfectants used.
DISINFECTANT DESCRIPTION MANUFACTURER, LOCATION
Birex SE Concentrate Dual phenolic, water based Biotrol (Earth City, Mo.)
CaviCide Spray Quaternary ammonium compound Metrex (Orange, Calif.)
plus isopropanol
Diluted Bleach 1:10 diluted sodium hypochlorite Clorox (Oakland, Calif.)
DisCide ULTRA Disinfecting Spray Quaternary ammonium compound Palmero Health Care (Stratford, Conn.)
plus alcohol
Lysol Brand II IC Disinfectant Spray Quaternary ammonium compound Reckitt Benckiser, Parsippany, N.J.
plus alcohol
Opti-Cide3 Solution Quaternary ammonium compound Biotrol (Earth City, Mo.)
plus alcohol

Conn.), Lysol Brand II IC Disinfectant Spray the center (1.0 square centimeter) of each sam-
(Reckitt Benckiser, Parsippany, N.J.) and Opti- ple with 0.1 mL of defibrinated sheep blood. I let
Cide3 solution (Biotrol) (Table 1). I mixed the the thin film of blood dry for 60 minutes, and
Birex SE formulation with tap water according then I disinfected the surface and obtained a
to the manufacturer’s recommendations. Tap sample of it to test for residual blood.
water served as a nonchemical control. To obtain samples to test for residual blood, I
The manufacturers of Birex SE, CaviCide, rotated a single cotton swab moistened in saline
DisCide ULTRA Disinfecting Spray and Opti- over the entire soiled area. I then placed the
Cide3 claim their products are surface cleaners swab into a tube containing 2.0 mL of saline and
and disinfectants.12-14 The manufacturer of Lysol vortexed it for 30 seconds. I tested for the pres-
Brand II IC Disinfectant Spray has specific dis- ence of blood by using dipstick tests designed to
infection claims about surfaces already detect minute amounts of blood in urine
cleaned,15 and the manufacturer of the bleach (Hemastix, Bayer, Leverkusen, Germany). After
diluted 1:10 with tap water has nonspecific, 60 seconds, I measured the color intensity by
general antimicrobial claims.1 Although bleach comparing the results to a standard color chart
is not an EPA-registered product, the Centers on the packaging. The small area on the stick
for Disease Control and Prevention considers containing the reactive chemicals turned blue-
diluted household bleach (5.25 percent) an effec- green if blood was present. Scores range from 0
tive and inexpensive disinfecting agent.1 to 6. A score of 0 indicates solutions containing
Spray disinfection. I used the standard no red blood cells; a score of 6 indicates the
spray-wipe-spray method to disinfect the sur- presence of 350 or more red blood cells.
faces. I sprayed an average of 0.75 milliliters of Statistical analysis. I analyzed study
the disinfectant to cover each test surface results by using a paired t test scheme (IBM
entirely. Using a c-fold paper towel, I wiped the SPSS Statistics 19, IBM, Somers, N.Y.). The
disinfectant up and down the surface 10 times. I risk level was .05 at a minimum. I analyzed dif-
applied the disinfectant a second time to com- ferences in test surfaces and disinfectants with
plete disinfection. After the exposure time rec- regard to blood removal test results.
ommended by the manufacturer, I wiped the A study with 10 samples per surface-
surface with a second paper towel to remove any disinfectant pairing had an 80 percent power for
residual disinfectant. detecting a difference of at least 50 percent in
Experiment. I estimated, on the basis of dis- the percentage of samples with blood removal
infection of dental operatory clinical contact sur- change, according to a two-sided χ2 test with a
faces occurring 10 times per day in dental prac- 5 percent significance level. I used statistical
tices that are open four days per week for 48 software (NCSS 2007, NCSS, Kaysville, Utah)
weeks per year, that each surface is disinfected to calculate sample size.
1,920 times per year.
Repeated disinfection can lead to loss of or RESULTS
change in surface integrity, which could affect The baseline scores in this study were the
the efficiency of disinfection cleaning. Therefore, cleaning scores I obtained when I used the con-
before the first disinfection procedure and after trol. I disinfected the surfaces by using the
every 100 disinfection procedures, I tested the standard spray-wipe-spray method. I tested all
surfaces by using a blood removal test. I covered disinfectants, even though diluted bleach and

474 JADA 143(5) http://jada.ada.org May 2012


Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH

TABLE 2

Blood removal scores.*


DISINFECTANT† SURFACE,‡ MEAN SCORE ± STANDARD ERROR OF THE MEAN
Acrylic Brushed Enameled High- Laminated, Service Smooth Smooth Textured
Resin Aluminum§ Metal§ Impact Heat-Resistant Line Stainless Vinyl§ Vinyl§
Sheets§ Plastic§ Thermosetting Rubber Steel§
Plastic§ Hosing§
Birex SE 3.00 ± 5.12 ± 0.07a 4.55 ± 1.85 ± 2.49 ± 0.06e 4.50 ± 2.50 ± 5.68 ± 6.00 ±
Concentrate 0.65k 0.35c 0.28g 0.16i 0.26o 0.06m 0.00r
CaviCide Spray 3.00 ± 3.38 ± 0.98a 5.00 ± 2.56 ± 4.45 ± 0.39f 4.60 ± 4.50 ± 6.00 ± 6.00 ±
0.93k 0.88c 0.44g,h 0.88i 0.34p 0.00n 0.00r
Diluted Bleach 4.45 ± 6.00 ± 0.00b 6.00 ± 2.98 ± 6.00 ± 0.00f 6.00 ± 2.00 ± 4.60 ± 6.00 ±
0.13l 0.00d 0.23h 0.00j 0.66o 0.88m 0.00r
DisCide ULTRA 5.00 ± 6.00 ± 0.00b 6.00 ± 2.96 ± 5.50 ± 0.45f 6.00 ± 6.00 ± 6.00 ± 6.00 ±
Disinfecting 0.37l 0.35d 0.34h 0.00j 0.00q 0.00n 0.00r
Spray
Lysol Brand II IC 4.45 ± 6.00 ± 0.00b 6.00 ± 3.67 ± 2.00 ± 0.24e 6.00 ± 2.80 ± 6.00 ± 6.00 ±
Disinfectant 0.03l 0.00d 0.18h 0.00j 0.88o 0.00n 0.00r
Spray
Opti-Cide3 3.02 ± 5.70 ± 0.69a 2.88 ± 2.90 ± 2.55 ± 0.44e 4.50 ± 5.65 ± 6.00 ± 6.00 ±
Solution 0.33k 0.82c 0.48h 0.28i 1.34q 0.00n 0.00r
Tap Water 4.32 ± 4.50 ± 1.13a 4.80 ± 3.50 ± 3.25 ± 0.11e 4.00 ± 2.60 ± 6.00 ± 6.00 ±
0.88k 0.28c 0.56h 0.44i 0.32o 0.00n 0.00r
* Scores after 1,920 disinfection procedures had been performed. Scores range from 0 to 6. A score of 0 indicates no red blood cells; a score
of 6 indicates the presence of 350 or more red blood cells.
† The products’ manufacturers are listed in Table 1.
‡ Ten samples per surface.
§ Scores designated by a common superscript letter in each column were statistically similar at a confidence level of at least 95 percent.

Lysol Brand II IC Disinfectant Spray’s manufac- clean a standardized amount of blood off a sur-
turers made only disinfection claims as opposed face, I conducted t tests to compare initial
to cleaning and disinfection claims. cleaning scores with those obtained after 1,920
Changes in sample surface integrity would be disinfection procedures had been performed for
due to the mechanical interaction of the paper each surface-disinfectant pairing (Table 3). The
towel and the test surface in the absence of a use of Opti-cide3 resulted in the fewest signifi-
chemical disinfectant. The disinfection process cant differences, followed by the use of Birex
could make the test surfaces rougher or duller SE, which decreased blood removal significantly
or possibly buff them smoother. In either case, on only one surface: enameled metal. The use of
the important factor was monitoring changes in the control resulted in decreased blood removal
cleanability—whether it was easier or more dif- on four of the surfaces (enameled metal; lami-
ficult to remove blood. nated, heat-resistant thermosetting plastic;
Table 2 shows blood removal scores for the acrylic resin sheets; and high-impact plastic).
nine test surfaces after 1,920 disinfection pro- Diluted bleach affected the surfaces the most
cedures had been performed for each surface- and resulted in statistically significant differ-
disinfectant pairing. I found that, in general, ences, indicating a decrease in blood removal on
DisCide ULTRA Disinfecting Spray had the all but two surfaces. The other three disinfec-
highest blood removal scores (greatest amount of tants had results that varied according to the
residual blood). Diluted bleach and Lysol Brand type of surface that underwent disinfection.
II IC Disinfectant Spray had similar scores. DisCide ULTRA Disinfecting Spray had the
Birex SE had the lowest overall blood removal highest blood removal scores. Diluted bleach
scores (least amount of residual blood) compared and Lysol Brand II IC Disinfectant Spray had
with the other disinfectants. In some pairings, similar scores, and Birex SE had the lowest
the control had lower blood removal scores com- overall blood removal scores compared with
pared with those of some of the disinfectants. those of the other disinfectants. In some pair-
Smooth and textured vinyl, enameled metal and ings, the control had lower blood removal scores.
service line rubber hosing were the most difficult
surfaces to clean at the end of the study because DISCUSSION
of surface degradation. A decrease in a surface’s cleanability after being
To measure the ability of a disinfectant to disinfected multiple times could be the result of

JADA 143(5) http://jada.ada.org May 2012 475


Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH

TABLE 3

Differences between beginning and ending cleaning values.


SURFACE DISINFECTANT,* SIGNIFICANCE (P VALUE)
Birex SE CaviCide Diluted DisCide Lysol Opti-Cide3 Tap Water
Concentrate Spray Bleach ULTRA Brand II IC Solution
Disinfecting Disinfectant
Spray Spray
Acrylic Resin NS† NS SS‡ < .01 SS < .01 SS < .01 NS SS < .05
Sheets
Brushed NS SS < .05 SS < .05 NS NS NS NS
Aluminum
Enameled Metal SS < .01 SS < .01 SS < .01 SS < .01 SS < .01 NS SS < .05
High-Impact NS SS < .05 SS < .05 SS < .05 SS < .05 NS SS < .01
Plastic
Laminated, NS SS < .05 SS < .05 SS < .05 SS < .05 NS SS < .05
Heat-Resistant
Thermosetting
Plastic
Service Line NS SS < .05 SS < .01 NS NS NS NS
Rubber Hosing
Smooth NS SS < .05 NS SS < .05 SS < .05 NS NS
Stainless Steel
Smooth Vinyl NS NS SS < .05 NS NS NS NS
Textured Vinyl NS NS NS NS NS NS NS
* The products’ manufacturers are listed in Table 1.
† NS: Not significant.
‡ SS: Statistically significant.

changes in the surface’s integrity. Mechanical Ten samples per group should have been suffi-
action associated with wiping, as well as pos- cient for statistical analysis. The relative
sible chemical effects resulting from surface- amount of blood used to soil each surface was
disinfectant pairings could affect the removal of considerably more than that normally found on
surface contamination negatively. dental office environmental surfaces. Finally,
The blood removal test involving 0.1 mL of the blood detection test was open ended. Al-
blood that I used to measure cleaning was though the test was highly sensitive, a score of 6
demanding. Dental office personnel should not indicted the presence of approximately 350 or
often encounter such amounts of blood. The more red blood cells. I could not determine how
larger amount of blood used in this study, how- much higher the quantity of red blood cells was
ever, appeared to help differentiate the by using the dipstick test.
cleaning actions of the disinfectants under
demanding circumstances. Disinfectants with CONCLUSIONS
known good cleaning abilities appeared to have I conducted this study to measure the effect
the advantage. long-term disinfection had on common types of
Ideally, a disinfectant should produce results dental office environmental surfaces. In general,
that mimic those of water’s effect on the surface the repeated use of disinfection procedures
across time. The effects of mechanical action (even when using the control) resulted in sur-
(repeated rubbing of surfaces with a paper face deterioration and increased difficulty in
towel) should produce similar results. Differ- blood removal. After comparing the test prod-
ences in cleanability should come from exposure ucts’ results to the control’s results and ac-
to specific disinfectants. Birex SE had surface knowledging the limitations of the study, I
integrity and blood removal results equal to or found that Birex SE consistently had better
in some cases better than those of the control. blood removal scores across time, which may
The least effective disinfectant was diluted indicate that less surface deterioration occurred,
bleach. compared with those of the other disinfectants
The study had limitations. Even though they and the control. DisCide ULTRA Disinfecting
were representative, I tested only nine surface Spray had the poorest blood removal results.
types and six disinfectant agents with fixed CaviCide and Opti-Cide3 had similar blood
active agent concentrations and formulations. removal scores, and diluted bleach and Lysol

476 JADA 143(5) http://jada.ada.org May 2012


Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH

Brand II IC Disinfectant Spray had higher Acinetobacter species. Am J Infect Control 2010;35(5 suppl 1):
S25-S33.
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and after contact with the skin of colonized patients. Infect Control
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metal surfaces in dental offices should be min- coccus aureus (published online ahead of print Oct. 28, 2010). Infect
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