THE AIR WATER SYRINGE!
That's correct.
This simple device is never sterilized.
Once a syringe is attached to the chair delivery system, it remains in place without ever being removed. For 10, 15, or even 20 years, this device may be used on patients without ever undergoing sterilization.
What does this imply? It suggests that thousands of patients received treatment with a non- sterilized air/water syringe. How is this possible? While most dental devices attached to the chair system can be removed for sterilization, the typical US, CAN, UK and AU air/water syringe cannot. Despite significant progress in developing safer dental devices, archaic syringes continue to be installed and sold, despite CDC recommendations that all air water syringes be heat sterilized between patients. That’s right, your air-water syringe is a semi-critical device and should be heat sterilized just like your other dental devices.
Why do only four countries still sell air water syringes that you cannot sterilize? (US, CAN, AU and UK) All of our European counterparts stopped selling and shipping noncompliant, nonsterilizable air water syringes over 15 years ago.
Next time at the dental office...
Ask Your Dentist or Hygienist Why They Have Not Upgraded in 30+ years.
Each of the syringes shown below should evoke concern for you and your family. If you encounter these devices in a dentist's or orthodontist's office, you can be sure that they have never undergone a sterilization process.
Air Water Syringe
Example 1
Air Water Syringe
Example 2
Air Water Syringe
Example 3
Air Water Syringe
Example 4
Air Water Syringe
Example 5
Air Water Syringe
Example 6
Air Water Syringe
Example 7
Air Water Syringe
Example 8
WATCH OUT!
If you see any of these air water syringes being used in your dental office, know they have NEVER been heat-sterilized between patients. 5, 10, and sometimes 15 years of this device being used on every patient for every procedure and never heat-sterilized. This is an indicator that your dental professional is falling behind on up to date infection control procedures. The CDC calls on for continuous improvement and expectations for a basic safe dental visit.
Every doctor and hygienist has had since 1992 to change to an autoclavable syringe, per FDA recommendations, back in the day to sterilize your dental handpiece and associated instruments such as the air/water syringe and ultrasonic scaler. That’s right, every dental professional was told at the exact same time AIDS was discovered in dentistry that they were to autoclave not just their handpiece but their air water syringe as well.
It appears that the highest standard of care, self-governance, and what’s best for the safety of the patient does not apply.
EVEN DISINFECTED, DENTAL SYRINGES HARBOR BACTERIA
Here is an example of an air water syringe in a dental practice. A product called GloGerm was sprayed on the air water syringe to see if there was still active bacteria on it after a post-op disinfection was completed.
As you can see, the air water syringe, even after it was disinfected, still had active bacteria on it from the previous patients.
DO YOU KNOW HOW MOST AIR WATER SYRINGES ARE DISINFECTED?
It goes against CDC guidelines for proper infection control. (CDC guidelines state if a semi-critical device is not heat tolerant at this point, the DHCP should replace it with a heat-tolerable or disposable alternative)
Desinfecting Wipes
The majority of dental offices clean their air water syringe with a simple disinfecting wipe. Never sterilizing it!
After blood, tissue, and contaminated aerosol sprays onto the air water syringe from one patients’ treatment, a dental assistant simply wipes down the syringe with a disinfecting wipe. After the quick wipe down, the next patient is brought in, and the next treatment begins. The problem with this procedure is that there are crevices and buttons on the air water syringe that cannot be cleaned by a simple wipe down. The aerosolized spray back also gets all over the air water syringe. These parts are not removed for inspection, let alone wiped down. Yet this has become the standard cleaning protocol for an air water syringe.
Would you feel safe knowing that this device had not undergone proper cleaning for ten years' worth of patients? How would you feel if a high-risk patient was treated just before you? Would you still accept your treatment?
Most dental offices have never updated their air water syringe, never mind reading the protocol from the CDC on how the air water syringe is supposed to be sterilized between patients, and it’s not.
Barrier sleeves
The other protective measure that is most commonly used for dental infection control are barrier sleeves. These sleeves are put over the device as a protective barrier from the splash back and contaminated aerosol.
Dentists and hygienists commonly believe that using barrier sleeves makes air water syringe contamination-free. However, the reality is different; removing barrier sleeves without contaminating the syringe is impossible as they extend beneath the syringe holder. To remove them, one must use a gloved hand, thus risking contamination.
Moreover, barrier sleeves have a slit for inserting tips, allowing debris like blood, saliva, and tissue to enter the sleeve, increasing the risk of dental cross-contamination potentially.
Changing gloves frequently to prevent contamination is often impractical in dental practice. The barrier is no substitution for sterilization, despite what any dental office may tell you. It does not deliver the highest standard of care if autoclavable syringes are available and not being used. The barrier could act as another shield but never a substitute for sterilization.
IS THE AIR WATER SYRINGE SUPPOSED TO BE STERILIZED?
The air water syringe, also known as a 3 way syringe, a triplex syringe or a 3-in-1 syringe, is classified as a semi-critical device by the CDC. This means the air water syringe should be heat- sterilized between patients. It’s not just us and the CDC saying this. See what other leading health authorities’ are recommending:
Dental Handpiece Sterilization - 1992
Food Drug Administration (FDA) recommends that reusable dental handpieces and related instruments (such as air/water syringes and ultrasonic scalers) be heat sterilized between each patient use. Handpieces that cannot be heat sterilized should be retrofitted to attain heat tolerance. Handpieces that cannot be retrofitted and thus not heat sterilized should not be used. Chemical disinfection is not recommended.
Food Drug Administration (FDA)
United States
Guidelines for Infection Control in Dental Health-Care Settings - 2003
Heat methods can sterilize dental handpieces and other intraoral devices attached to air or waterlines (246,275,356, 357,360). For processing any dental device that can be removed from the dental unit air or waterlines, neither surface disinfection nor immersion in chemical germicides is an acceptable method.
Centers for Disease Control and Prevention
DeKalb County, United States
Guideline for Disinfection and Sterilization in Healthcare Facilities - 2008
In addition, after each use, sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (e.g., amalgam condensers, air-water syringes) but that might contact oral tissues and are heat-tolerant, although classified as semicritical. Clean and, at a minimum, high- level disinfect heat-sensitive semicritical items. Category IA.
Centers for Disease Control and Prevention
DeKalb County, United States
Summary of Infection Prevention Practices in Dental Settings: Sterilization and Disinfection
Because the majority of semicritical items in dentistry are heat-tolerant, they should be sterilized using heat. If a semicritical item is heat-sensitive, the DHCP should replace it with a heat-tolerant or disposable alternative. If none are available, the item should, at a minimum, be processed using high-level disinfection.
Food Drug Administration (FDA)
United States
Guideline for Disinfection and Sterilization in Healthcare Facilities - 2008
Scientific articles and increased publicity about the potential for transmitting infectious agents in dentistry have focused attention on dental instruments as possible agents for pathogen transmission 207, 208. The American Dental Association recommends that surgical and other instruments that normally penetrate soft tissue or bone (e.g., extraction forceps, scalpel blades, bone chisels, periodontal scalers, and surgical burs) be classified as critical devices that should be sterilized after each use or discarded. Instruments not intended to penetrate oral soft tissues or bone (e.g., amalgam condensers, and air/water syringes) but that could contact oral tissues are classified as semicritical, but sterilization after each use is recommended if the instruments are heat-tolerant.
...Heat-tolerant alternatives are available for most clinical dental applications and are preferred.
Centers for Disease Control and Prevention
DeKalb County, United States
Module 7 - Sterilization and Disinfection of Patient-Care Items and Devices
Semicritical Items
- Lower risk of transmission
- Should be heat sterilized or high-level disinfected
- NOTE: If a semicritical item is heat-sensitive, DHCP should replace it with a heat-tolerant or disposable alternative. If none are available, the item should, at a minimum, be processed using high-level disinfection.
Food Drug Administration (FDA)
United States
CDC Statement on Reprocessing Dental Handpieces - 2018
If a dental handpiece cannot be heat sterilized and does not have FDA clearance with validated instructions for reprocessing, DHCP should not use that device.
Centers for Disease Control and Prevention
DeKalb County, United States
Summary of Infection Prevention Practices in Dental Settings
Because the majority of semicritical items in dentistry are heat-tolerant, they should also be sterilized using heat. If a semicritical item is heat-sensitive, DHCP should replace it with a heat- tolerant or disposable alternative.
Centers for Disease Control and Prevention
DeKalb County, United States
Infection and Sterilization
The ADA urges all practicing dentists, dental auxiliaries and dental laboratories to employ appropriate infection control procedures as described in the 2003 CDC Guidelines, and the 2016 CDC Summary and to keep up to date as scientific information leads to improvements in infection control, risk assessment, and disease management in oral health care.
American Dental Assoication
Chicago, Illinois
Infection Control: Guidelines for Practice Success | Managing Regulatory | Centers for Disease Control and Prevention
Use CDC’s Infection Prevention Checklist for Dental Settings: Basic Expectations for Safe Care to help make sure the practice is in compliance
American Dental Assoication
Chicago, Illinois
CDC Guidelines & Recommendations
Al dental settings, regardless of the level of care provided, must make infection prevention a priority and should be equipped to observe Standard Precautions and other infection prevention recommendations contained in the CDC Guidelines for Infection Control in Dental Health-Care Settings-2003
Organization for Safety, Asepsis & Prevention
Atlanta, Georgia
Re: Sterilization of Dental Instruments and Handpieces
Despite this information, a review of Joint Commission survey data has identified either a lack of awareness of the requirements or misinterpretation of manufacturer’s instructions — in addition to a lack of staff training and leadership oversight — related to the sterilization of dental devices. This has resulted in multiple declarations of an Immediate Threat to Health and Safety of patients.
For this reason, if an organization has been improperly reprocessing dental handpieces or any other instruments requiring sterilization using sterilization parameters that do not match the device (e.g., handpiece) manufacturer instructions they should seek assistance from their local health department or state healthcare associated infection liaison for assistance in determining if any patient follow-up is indicated.
The Joint Commission
Oakbrook
Infection Prevention and Control
Select an infection control guideline applicable to dental (i.e. CDC Dental Infection Prevention Guidelines)
The Joint Commission
Oakbrook Terrace, Illinois* In no way should any of these statements be interpreted as endorsements. The statements made from these regulatory agencies are merely stating procedures and recommendations to the dental health care professional (DHCP) from the public forum.
Research Studies
If the CDC, FDA, ADA, and OSAP recommendations still are not enough for you.
Let’s see what science and evidence has to say.
Air Water Syringe Research Studies
The detection of blood on dental surgery surfaces and equipment following dental hygiene treatment
British Dental Journal
1994; 176:65
Demystifying the mist: Sources of microbial bioload in dental aerosols
Journal of Periodontal
2020 Sep;91(9):113-1122
Isoenzyme genotyping and phylogenetic analysis of oxacillin-resistance Staphylococcus aureus isolates
Brazilian Journal of Oral Sciences
2017 Dec; Vol.16
Dynamics of the seasonal airborne propagation of Staphylococcus aureus in academic dental clinics
Journal of Applied Oral Science
2018 Apr 5;26 e:20170141
Disinfectants Used in Stomatology and SARS-CoV-2 Infection
European Journal of Dentistry
2020 Oct, 27: DOI 10.1055/s-0041-1724154
Staphylococcus Aureus Contamination in a Pediatric Dental Clinic
The Journal of Clinical Pediatric Dentistry
2009 Fall;34(1):13-18
Aerosols and splatter in dentistry
Journal of the American Dental Association
2004 Apr;135(4):429-37
Using a Biological Indicator to Detect Potential Sources of Cross-Contamination in the Dental Operatory
Journal of the American Dental Association
1998 Nov;129(11):1567-77
Changes in dental practice in times of COVID-19: review and recommendations for dental health care
Rev. Gauch Odontol
2021;Odontol:69
Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2
IntechOpen
2018 Nov;10.5772/intechopen.81494
Nosocomial transmission of methicillin- resistant Staphylococcus aureus via the surfaces of the dental operatory
British Dental Journal
2006 Sep 9;201(5);297-300
A clinical observational analysis of aerosol emissions from dental procedures
PLOS ONE
2022 Mar 10;17(3);e0265076
High‐volume evacuation mitigates viral aerosol spread in dental procedures
Scientific Reports
2023 Nov 3;13(1);18984
The air-water syringe: contamination and disinfection
Quintessence Internationa
1989 Dec;20(12);911-16Aerosolization Research Studies
COVID-19 Pandemic and Role of Human Saliva as a Testing Biofluid in Point-of-Care Technology
European Journal of Dentistry
2020; 14(suppl S1):S123-S129
Effective and practical recommendations to dental team when providing dental services in the era of COVID-19
Rwanda Medical Journal
2022; Vol.79, no.2
A scoping review on bio-aerosols in healthcare and the dental environment
PLOS ONE
2017 May; 13(5): e0178007
Influence of flow rate and different size of suction cannulas on splatter contamination in dentistry: results of an exploratory study with a high‐volume evacuation system
Clinical Oral Investigations
(2022) 26:5687–5696
A systematic review of droplet and aerosol generation in dentistry
Journal of Dentistry
105 (2021) 103556Current Air Water Syringe Designs Do Not Meet Leading Health Authorities' Recommendations
Still left with non-sterile device after all this work
Doesn’t meet current recommendations
Increases environmental waste
Increases liability vs sterile solution
Increased associated costs
Decreased office chair time
... Because the mojority of semi critical items in dentistry are heat-tolerant, they should be sterilized using heat. If a semi critical item is heat sensitive, the DHCP should replace it with a heat-tolerant or disposable alternative.
LEADING HEALTH AUTHORITIES' RECOMMENDATIONS
Therefore, handpieces and other intraoral instruments should be removed from the air and waterlines of dental units, cleaned, and heat-sterilized between patients...
CDC Recommendations
Dental Instruments
Scientific articles and increased publicity about the potential for transmitting infectious agents in dentistry have focused attention on dental instruments as possible agents for pathogen transmission207, 208. The American Dental Association recommends that surgical and other instruments that normally penetrate soft tissue or bone (e.g., extraction forceps, scalpel blades, bone chisels, periodontal scalers, and surgical burs) be classified as critical devices that should be sterilized after each use or discarded. Instruments not intended to penetrate oral soft tissues or bone (e.g., amalgam condensers, and air/water syringes) but that could contact oral tissues are classified as semicritical, but sterilization after each use is recommended if the instruments are heat-tolerant... Heat-tolerant alternatives are available for most clinical dental applications and are preferred.
CDC Recommendations
Management of Equipment and Surfaces In Dentistry
In addition, after each use, sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (e.g., amalgam condensers, air-water syringes) but that might contact oral tissues and are heat-tolerant, although classified as semicritical. Clean and, at a minimum, high- level disinfect heat-sensitive semicritical items.
CDC Recommendations
Basic Expectations for Safe Care: Summary of Infection Prevention Practices in Dental Settings
Because the majority of semicritical items in dentistry are heat-tolerant, they should be sterilized using heat.
If a semicritical item is heat-sensitive, the DHCP should replace it with a heat-tolerant or disposable alternative.
CDC Recommendations
Special Considerations Dental Handpieces and Other Devices Attached to Air and Waterlines
Heat methods can sterilize dental handpieces and other intraoral devices attached to air or waterlines. For processing any dental device that can be removed from the dental unit air or waterlines, neither surface disinfection nor immersion in chemical germicides is an acceptable method.
CDC Recommendations
This is to notify you that the Food and Drug Administration (FDA) recommends that reusable dental handpieces and related instruments (such as air/water syringe and ultrasonic scalers) be heat sterilized between each patient use.
CDC Recommendations
In April, 2018, the CDC released a Statement on Reprocessing Dental Handpieces stressing that handpieces (both low-speed and high-speed) and other intraoral instruments that can be removed from the air lines and waterlines need to be heat sterilized between patients and that reusable devices made prior to 2015 may not meet current FDA reprocessing guidance.
CDC Recommendations
In keeping with Centers for Disease Control and Prevention, American Dental Association, and OSAP recommendations, your dentist should be heat-sterilizing all instruments that penetrate or contact a patient’s oral tissues.
CDC Recommendations
For individuals prioritizing compliance, regulatory adherence, or vigilant risk management, CrystalGenics stands as an essential consideration for your office environment. Endorsed by prominent authorities including the CDC, ADA, FDA, and OSAP, the necessity of heat-sterilizing the air/water syringe between patients is underscored. However, the challenge arises with conventional air/water syringes, which, once installed, lack the capability for heat sterilization due to their fixed nature. CrystalGenics provides a solution to this dilemma through its innovative to their fixed nature. CrystalGenics provides a solution to this dilemma through its innovative heat-tolerant sleeve, enabling effortless removal within seconds between patient procedures.
Sponsor Benefit
HOW TO IDENTIFY COMPLIANT AIR WATER SYRINGES.
If you are using a CDC compliant air water syringe you should see a 135 ̊ C symbol located somewhere on the body of the syringe. If you do not see this symbol, you should not be using that air water syringe.
Non Autoclavable air water syringe
Autoclavable air water syringe
Non Autoclavable air water syringe
Autoclavable air water syringe
If you do not have additional syringe sleeves to replace the air water syringe between patients, you are using a non-compliant air water syringe.
If you cannot remove the syringe between patients, you are using a non-compliant air water syringe.
If your air water syringe doesn't meet any of these points, you should not be using it. For over 30 years the CDC and FDA have stated the air water syringe produces more contaminated aerosols than any other device in the dental office. The air water syringe is a major contamination point and only an autoclavable alternative solves this issue.
Alternatives Are Available
Most chair manufacturers produce a proper air/water syringe, however, most do not sell them! Instead they opt to cheapen the product, put the patient at risk, and most dental professionals are not even aware they are not following CDC guidelines on this device. The good news is we show there are plenty of options for the dental community to upgrade their air-water syringes and place patient safety above all else.
The following air/water syringes, once installed to a delivery system, can be removed and heat-sterilized between patients. By upgrading your air water syringe, you will be reducing the chances of dental cross contamination and making your office compliant to safe standards set forth by the CDC.
Adec
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
CrystalGenics
Air Water Syringe
DCI
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Cefla Anthos F3/F6
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Cefla SP
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Faro SM03
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Faro SYR
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Kavo Estetica
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Kavo K4
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Sirona C8
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Luzzani MiniLight
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Luzzani MiniBright
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Morita WS-97
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Osada MS-F
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
Yoshida 3-ST
Air Water SyringeAutoclavable Version Only. Inspect the handle to verify a sterilization symbol is present.
* Adec, CrystalGenics, Cefla Anthos, Faro, Kavo, Dentspy Sirona, Luzzani, Osada, and Yoshida are registered trademarks of their respective companies and are in no way associated with Dentistry's Dirty Secret or any of it's affiliates.
In the USA, the majority of dental offices use older model air water syringe designs and continue to overlook safer alternatives.
In fact, most dental health care professionals, don't even know these autoclavable alternative air water syringes exist! In the USA, CrystalGenics air water syringes, Adec (autoclavable) air water syringes, and DCI (autoclavable) air water syringes are the most readily available safe alternatives. As you can see, dentists and hygienists do have safer alternatives that are available. Problem is when dental offices purchase dental units, they are not told they are buying equipment that doesn’t meet leading health authorities’ recommendations. If alternatives are available, but offices are not made aware of these alternatives, how would they know what they are purchasing is non- compliant?
The dental industry as a whole needs to educate themselves on device sterilization protocols and understand as science and technology improves, so should the equipment they use. Now it is up to the dental office to take infection control more seriously and become compliant with leading health authorities’ recommendations.
Why do these countries still sell dental chairs with air/water syringes that cannot be removed to be heat-sterilized between patients?
The USA, UK, Canada, and Australia are some of the only countries that still allow dental chairs to be sold with non-autoclavable air/water syringes.
Why is this still a thing? The air/water syringe is known to produce the most aerosolized contaminants during procedures, yet manufacturers still do not give an option for a safer alternative? In Europe, every chair sold comes with an air/ water syringe that can be removed and heat-sterilized between patients.
It's not just us saying this. Take a look at chairs sold in Europe.