ASSESSING THE EFFECTIVENESS OF DIRECT DIGITAL
RADIOGRAPHY BARRIER SHEATHS AND FINGER COTS
STEVEN D. HOKETT, D.D.S.,
JAMES R. HONEY, D.M.D.,
FRANCISCO RUIZ, D.M.D.,
MICHAEL K. BAISDEN, D.D.S. and
MICHAEL M. HOEN, D.D.S.
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ABSTRACT
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Background. Effective cross-contamination prevention is critical for direct digital radiography, or DDR, sensors, which are not sterilizeable; however, current manufacturers’ recommendations for standard precautions are limited to the use of plastic barrier sheaths, which are commonly known to tear or leak. The authors sought to determine the incidence of digital radiography barrier-sheath leakage, with and without additional latex finger cot protection, as measured by a water pressure test.
Methods. Four hundred plastic barrier sheaths were randomly assigned to four groups based on intraoral radiograph positioning device use and supplemental barrier protection with a latex finger cot. Sheaths were carefully placed to cover DDR sensors for a single intraoral use, gently removed from the sensors and tested for leakage through a water pressure technique.
Results. Perforations occurred in 44 to 51 percent of plastic sheaths after a single radiographic exposure. However, only up to 6 percent of the plastic sheaths that were covered by a latex finger cot leaked during the water pressure test.
Conclusions. At least 44 percent of the plastic barrier sheaths leaked after a single intraoral radiographic exposure. Use of a latex finger cot over the plastic sheath significantly reduced leakage to no more than 6 percent.
Clinical Implications. Latex finger cots used in conjunction with the standard plastic sheaths that cover DDR sensors may more effectively prevent cross-contamination than do plastic sheaths alone. Dentists who use DDR sensors during highly invasive dental procedures such as dental implant surgery are encouraged to consider supplemental barrier protection for these delicate, expensive and nonsterilizeable sensors to prevent patient cross-contamination.
Computer advances continue to profoundly affect the clinical practice of dentistry and are no longer limited to practice management applications. Interactive patient education, video imaging, caries detection, orthodontic diagnosis, periodontal probing, postmortem identification and long-distance consulting are commonly used computer applications in modern dental practices.1–7
One of the most exciting applications of computer technology in dentistry today is the direct digital radiography, or DDR, system, which produces a chemical-free and instantaneous dental radiographic image. DDR significantly enhances the dental practitioner’s ability to minimize radiation exposure, while improving efficiency and environmental responsibility, enhancing patients’ understanding of existing dental disease and providing excellent diagnostic visualization.8,9
Digitized radiographic information also can be used as part of an electronic consultation with practitioners at remote sites or can be filed for insurance purposes. Nonsurgical endodontic and surgical dental implant placement have been assisted significantly in recent years through the advent of the virtually instantaneous radiographic image.
DDR uses a special sensor, called a charged coupling device, that is placed into the mouth in place of an intraoral dental film. Sensors cannot be autoclaved, so it is important to use effective barrier techniques to protect them.
Dental health care providers continually strive to achieve effective infection control. Routine application of universal precautions has created a safer environment for dental personnel and patients through the use of multiple aseptic procedures, latex gloves, masks, protective eyewear, clinic coats, automated instrument decontamination devices, time-efficient heat sterilization, chemical disinfectants, waste management procedures and single-use disposable items.10–12
Although various infection control barriers have been recommended in dentistry, plastic sheaths are the standard precaution currently recommended by digital radiographic system manufacturers and the dental profession for the prevention of bacterial cross-contamination during DDR use.8,9,12 Our study as well as previous studies of barrier leakage have operated under the assumption that water leakage under pressure equates to bacterial contamination; however, this may not be true.13–16
The purpose of this study was to determine the incidence of DDR barrier-sheath leakage with and without additional finger cot protection as affected by the use of an intraoral radiograph positioning device. The null hypothesis states that there is no statistically significant difference between using a latex finger cot over the plastic sheath and using the plastic sheath alone during intraoral DDR, as measured by barrier-sheath leakage.
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MATERIALS AND METHODS
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Four hundred plastic sheaths (Applied Technology) designed to cover DDR sensors (Schick Technologies Inc.) were randomly assigned to one of four groups based on the use of an intraoral radiograph positioning device (Rinn XCP) or latex finger cots (part number 3617, Nimba Inc.) that covered the plastic sheaths. Positioning devices were used because we believed them to be a potentially significant factor in plastic sheath wear. An additional 10 unused plastic sheaths served as controls and none showed any leakage with the water pressure test. Positioning devices were assembled and DDR sensors were then carefully covered with the plastic sheaths (Figures 1
and 2).
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Figure 1. Direct digital radiography sensor held by an intraoral radiograph positioning device and covered by a plastic barrier sheath and finger cot.
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Figure 2. Direct digital radiography sensor without an intraoral radiograph positioning device and covered by a plastic barrier sheath and finger cot.
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Two of us (J.H., F.R.) were calibrated in DDR sensor barrier application, intraoral sensor placement consistent with acceptable procedures for radiographic image production, and the careful removal of plastic sheaths and latex finger cots. One subject was used for each of the four experimental groups, and the actual radiographic exposure of 10 milliampere-seconds, 65 kilovoltage at 30 impulses for 0.5 second took place after the sensor was removed to prevent the subject’s receiving any radiation.
All samples were sealed and coded according to the examiner, use or nonuse of a positioning device and barriers used. We used a standard water pressure test to assess leakage from the plastic sheaths.14,15
We gently filled each plastic sheath with 30 cubic centimeters of tap water at room temperature and twisted the sheath three complete turns to create a seal. We applied moderate hand pressure for 30 seconds and visually checked the sheaths for water leakage (Figures 3 and 4). After all samples were examined for leakage, test codes were broken and the results were submitted for statistical analysis.
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STATISTICAL ANALYSIS
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A 
2 analysis was conducted to determine statistical differences (P < .05) in leakage between study groups (that is, presence or absence of an intraoral radiograph positioning device and presence or absence of finger cots).
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RESULTS
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The results of the study showed that the plastic barrier sheaths used to cover DDR sensors exhibited evidence of water leakage, with an overall leakage rate of 47.5 percent in groups 1 and 2 (Table). None of the control plastic sheaths leaked, suggesting that the process of fitting the sheath over the sensor may create weak spots in the sheath and subsequent leaks.
The 2 analysis revealed no statistical difference between groups with or without positioning devices when the presence of cots was disregarded (2 = 1.7; P = .19). Statistical analysis did reveal a highly significant difference between presence or absence of finger cots (2 = 79.22; P = .0001). We found that the use of latex finger cots over plastic barrier sheaths significantly (P < .0001) reduced water leakage to between 0 and 6 percent in groups 3 and 4.
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DISCUSSION
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The results of this study demonstrate the in vivo effectiveness of latex finger cots used in conjunction with plastic sheaths covering DDR sensors in significantly reducing the incidence of sheath perforation as measured by water leakage. Blood, microorganisms and other substances have been shown to pass through perforated latex gloves.16 This study assumes that water leakage under pressure through a barrier membrane equates to bacterial contamination; however, this has not been proved. Another possible weakness of this study is that the finger cot alone should have been tested; however, because of their short length, the cots would provide no barrier protection for the sensor cord, as does the plastic sheath. Further research in this area might focus on the establishment of bacterial penetration through the plastic sheath and subsequent bacterial attachment and growth on an agar plate, as measured in colony-forming units.
Clinicians who use DDR may want to consider the use of finger cots combined with plastic sheaths to help prevent cross-contamination from DDR sensors, especially during highly invasive procedures such as dental implant surgery. The finger cot is inexpensive and helps prevent barrier-sheath perforation. In addition, cots encase and compress the plastic sheath, which may aid in visualization during sensor placement as well as improve patient comfort.
The results of this study demonstrate the in vivo effectiveness of latex finger cots used in conjunction with plastic sheaths covering direct digital radiography sensors in significantly reducing the incidence of sheath perforation.
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CONCLUSIONS
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The integrity of plastic barrier sheaths may be an integral component in the prevention of cross-contamination from DDR sensors. We found an overall leakage rate of 3 percent (six sheaths out of 200) in groups 3 and 4, which had latex finger cots covering the plastic barrier sheath, vs. a 47.5 percent overall leakage rate in groups 1 and 2, which had plastic barrier sheaths alone. When an intra-oral radiograph positioning device was used, the leakage rate was reduced, but the difference was not statistically significant.
Health care practitioners who use DDR sensors may want to consider the routine use of the plastic barrier sheath combined with a finger cot to ensure the prevention of cross-contamination until improved sheaths are marketed. We strongly encourage practitioners who use DDR sensors during highly invasive dental procedures such as implant surgery to consider the additional barrier protection of a latex finger cot for these nonsterilizeable sensors. Manufacturers need to develop more effective barrier sheaths using improved plastics or longer latex sheaths. However, introduction of any new products will require additional research to verify their effectiveness.
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FOOTNOTES
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Dr. Ruiz is a comprehensive dental officer, U.S. Army Dental Activity, Fort Rucker, Ala.
Dr. Baisden is chief of endodontics and endodontics mentor, Advanced Education in General Dentistry, Fort Bragg, N.C.
The opinions expressed in this article do not represent those of the Department of Defense, the U.S. Army or the U.S. Army Dental Corps. The use of commercial products in this project does not imply endorsement by the U.S. Government.
The authors acknowledge Dr. Steve Hondrum for his help with the statistical analysis.
Dr. Hokett is assistant director, U.S. Army Periodontic Residency Program, Tingay Dental Clinic, Building 320, E. Hospital Road, Fort Gordon, Ga. 30905. Address reprint requests to Dr. Hokett.
At the time this study was conducted, Dr. Honey was a resident in Advanced Education in General Dentistry, Fort Bragg, N.C. He currently is a Dental Treatment Section Leader, U.S. Army 464th Medical Company (Dental Services), Landstuhl, Germany.
Dr. Hoen is an associate professor, Department of Endodontics, University of Detroit–Mercy School of Dentistry.
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ABSTRACT
MATERIALS AND METHODS
