Dental surgery and implantology: differences between a sterile field and a clean field
Usage and main differences
In dental practices, the two ways of preparing the working field, sterile and clean, share some common elements, but they also have substantial differences, which are crucial for the success of surgery procedures and patient safety. If, in fact, in everyday practice work is carried out under “clean” conditions, the creation of a “sterile” field is a standard adopted specifically in dental surgery procedures to ensure maximum protection for the patient, the surgical team and the dentist, as well as to ensure the successful outcome of the procedure. Both working conditions aim to prevent cross-contamination and the spread of harmful bacteria. However, some important differences should be highlighted:
- Under “sterile” working conditions, the aseptic technique is used, designed to prevent the introduction of pathogens into a sterile field. It requires advance preparation and additional precautions both before and during surgical procedures. The main aspects of this technique are: hand hygiene, use of Personal Protective Equipment, cleaning and disinfection of surfaces and sterilization of instruments. It also involves the use of sterile barriers, such as gowns, drapes, gloves and face masks, to create a barrier between the surgical area and potential sources of contamination. The creation of a sterile field is particularly important in dental implant surgery, where the goal is to reduce the possibility of contamination of the implant or bone graft during placement (Truant, 2018).
- Under “clean” working conditions, efforts are made to prevent cross-contamination and reduce the number of microorganisms in the environment. Therefore, the use of gloves, face masks, drapes and non-sterile barriers is required (Truant, 2018). The clean technique is not recommended for surgical procedures such as the insertion of endosseous implants (Veitz-Keenan et al, 2018).
Why operate under “sterile” working conditions?
Performing surgery, especially implantology, in a non-sterile field can lead to various complications, including:
1. Increased risk of infection (Hanif et al, 2017): without the use of sterile drapes and gowns, there is an increased risk of cross-contamination from the patient’s clothing, the healthcare professional’s clothing and the surrounding environment. This can lead to an increased risk of infection, which can cause complications in the healing process and in the success of the surgery. In addition, the sterile working field reduces the use of antibiotics in the post-operative course and thus limits the risk of adverse drug reactions and the emergence of bacterial resistance (Sancho-Puchades et al, 2009).
2. Osseointegration is compromised: in case of infection, it is possible to compromise osseointegration and thus lead to implant failure (Dhaliwal et al, 2020; Camps-Font, 2018). A study published in the British Dental Journal (Scharf and Tarnow, 1993) found that failures in implant dentistry were often due to infections and other complications resulting from non-sterile techniques.
3. Decreased implant survival rate (Scharf, 1993): studies have shown that implants placed in sterile conditions have a higher success rate than those placed in non-sterile conditions. A study published in the Journal of Periodontology found that implants placed under sterile conditions had a 98.9% success rate, while those placed under clean conditions had a 95.1% success rate.
Sterile field: what are the most common mistakes?
Maintaining a sterile field during dental implantology is essential to prevent infection and ensure the success of the procedure; however, operating in a sterile field requires the utmost care, and it is easy to make mistakes or produce inaccuracies that undermine the whole procedure. Here are some of the most common errors (Hopper et al, 2010):
1. Setting up and opening the sterile field: the process of setting up and opening the sterile field can be challenging and mistakes can be made. This may include contact with non-sterile surfaces, such as the floor or non-sterile equipment, or inadequate covering of the patient. These mistakes can lead to contamination of the surgical area.
2. Washing and dressing: Washing and dressing are essential steps in maintaining a sterile field, but even at this stage mistakes can occur. This may include not washing the gown or failing to put it on properly, or it may include contact with non-sterile surfaces during scrubbing or putting on the gown. These mistakes can lead to contamination of the surgical area.
3. Logistics: the movement and presence of people in the operating room can lead to contamination of the surgical area. This may include healthcare workers entering and leaving the room or non-sterile staff entering the room. It is important to minimise unnecessary movement and the presence of people in the operating room in order to reduce the risk of contamination.
4. Preparing the patient: patient preparation is a fundamental aspect of maintaining a sterile field, but even here mistakes can be made. This may include failure to adequately clean and disinfect the surgical area or failure to properly cover the patient. These mistakes can lead to contamination of the surgical area.
In conclusion, interruptions in sterile technique can occur during dental surgery. It is important to know the most common errors and their implications in order to prevent them and minimize the risk of contamination and infection (Simko, 2012).
What are the best measures to a maintain sterile field?
Here are some best practices for maintaining a sterile field during implant dentistry (Roark, 2003):
1. Use sterile barriers: use sterile gowns, drapes, gloves and face masks to create a barrier between the surgical area and potential sources of contamination. This helps prevent cross-contamination and reduces the likelihood of infection.
2. Preparation of the patient and equipment: use antiseptic skin preparation for the patient, sterile instruments and devices such as surgical handpieces, burs, drills, etc. All non-sterile drapes should be applied first (light handle covers, covers for the patient’s headrest, etc.) before draping the operating tray. All sterile items must be placed on a sterile field and handled by an assistant wearing sterile gloves.
3. Environmental controls: room doors must be kept closed, traffic entering and leaving must be kept to a minimum. In fact, the risk of air contamination increases the longer the sterile field is left open, thereby posing a risk to patient safety. Dust and particles from the environment can settle on the surfaces of the sterile field. Therefore, surgery departments should establish policies and procedures that address this problem and best meet patient needs.
4. Apply the contact-to-contact technique: according to this technique, only sterile-to-sterile contact is permitted. This means that only the second assistant will open non-sterile items and will not touch any sterile fields, instruments or equipment.
Sources
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Camps-Font O, Martín-Fatás P, Clé-Ovejero A, Figueiredo R, Gay-Escoda C, Valmaseda-Castellón E. Postoperative infections after dental implant placement: Variables associated with increased risk of failure. J Periodontol. 2018 Oct;89(10):1165-1173. doi: 10.1002/JPER.18-0024. Epub 2018 Sep 2. PMID: 29797721.
Chen A. Sterilized Aseptic Versus Sterilized Clean Field for Dental Implant Placement – Randomized Clinical Control Trial for Non-inferiority Comparison. 2023. https://clinicaltrials.gov/ct2/show/NCT01970826
Dhaliwal, J.S., David, S.R.N., Zulhilmi, N.R. et al. Contamination of titanium dental implants: a narrative review. SN Appl. Sci. 2, 1011. 2020.
Hanif A, Qureshi S, Sheikh Z, Rashid H. Complications in implant dentistry. Eur J Dent. 2017 Jan-Mar;11(1):135-140. doi: 10.4103/ejd.ejd_340_16. PMID: 28435381; PMCID: PMC5379828.
Hopper, W.R. and Moss, R. Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications. AORN Journal, 91: 350-367. 2010.
Roark J. “Guidelines for Maintaining the Sterile Field,” Infection Control Today 7(8) (August 2003) 14-16. 2003.
Sancho-Puchades M, Herráez-Vilas JM, Berini-Aytés L, Gay-Escoda C. Antibiotic prophylaxis to prevent local infection in Oral Surgery: use or abuse? Med Oral Patol Oral Cir Bucal. 2009 Jan 1;14(1):E28-33. PMID: 19
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Simko L. Breaking sterility: Dealing with procedural violations in healthcare. Nursing. 2012 Aug;42(8):22-6. doi: 10.1097/01.NURSE.0000415839.66736.4c. PMID: 22832623. https://www.mbit.org/cms/lib/PA03000116/Centricity/Domain/49/Articlwe%20breaking%20sterility.pdf
Truant K. Oral & Maxillofacial Surgery – A Handbook for Certified Dental Assistants. 2018. https://pressbooks.pub/oralsurgery4cdas/
Veitz-Keenan A, Ferraiolo DM, Keenan JR. Impact of asepsis technique on implant success. A review. Eur J Oral Implantol. 2018;11 Suppl 1:S113-S121. PMID: 30109303.
Ulteriori letture
Association of Surgical Technologists, AST. Guidelines for Best Practices for Establishing the Sterile Field in the Operating Room. 2019. https://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Guidelines%20Establishing%20the%20Sterile%20Field.pdf
Alberta Health. Surgical Aseptic Technique and Sterile Field. 2013. https://www.albertahealthservices.ca/assets/wf/eph/wf-eh-surgical-aseptic-technique-sterile-field.pdf