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-
fection is less lethal than is sterili-
zation because it destroys most rec-
ognized pathogenic microorganisms
but not necessarily all microbial
forms (for example, bacterial
spores).1
An estimated 1.7 million health
care–associated infections occur an-
nually in the United States, result-
ing in 99,000 deaths.2 The major
source of the involved pathogens is
patients’ endogenous flora; however,
an estimated 20 to 40 percent of
health care–associated infections
appear to be cross infections in-
volving the hands of health care
workers. Worker hand contami-
nation could result either directly
from patient contact or indirectly
from touching contaminated envi-
ronmental surfaces.3,4
Results from two recent studies
show the role hospital environments
play in methicillin-resistant Staphy-
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
Copyright © 2012 American Dental Association. All rights reserved.
AB STRACT
Background. The author measured the effect
long-term disinfection had on common types of
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CON
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dental office environmental surfaces.
T
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Methods. The author tested nine common A
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ED
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RT 2
G
dental surfaces and six spray disinfectants, as I C LE
well as a tap water control. The author used the “spray-
wipe-spray” method with paper towels to disinfect the surfaces.
Each surface was disinfected 1,920 times, which was an estimate of
the number of cleanings per year. After every 100 disinfections, the
author conducted blood removal testing of the surface, which moni-
tored residual blood and disinfectant cleaning ability.
Results. The surface that was most difficult to clean was tex-
tured vinyl, followed by smooth vinyl, enameled metal, service line
rubber hosing and brushed aluminum. Diluted bleach affected sur-
faces the most, which resulted in higher blood removal scores.
Conclusions. When compared with the control, Birex SE had
equal or better cleaning scores across time, which might indicate
that its use caused little change in the integrity of the surfaces.
The results for the other disinfectants varied.
Clinical Implications. Disinfectants should have good antimi-
crobial activity and minimal negative impact on the integrity of the
surfaces being disinfected. Effective disinfection is highly depen-
dent on efficient cleaning (removal of the bioburden present).
Key Words. Disinfection; environmental asepsis; surface
cleaning; surface integrity.
JADA 2012;143(5):472-477.
May 2012

sion and support the need for proper surface
cleaning and disinfection.5,6 Health care workers
are a clinically relevant source of cross infection.
One of the studies involved 40 patients with
MRSA who were admitted to a Veterans Affairs
hospital.6 The researchers found that hand con-
tamination among health care workers was
equally likely after contact with commonly
examined skin sites or with frequently touched
environmental surfaces in patient rooms (40
percent versus 45 percent, respectively).
Dental instruments, devices and equipment
fall into one of three categories—critical, semi-
critical or noncritical—depending on the risk of
development of an infection associated with
their intended use. Critical items penetrate soft
tissue or bone, have the highest risk of trans-
mitting infection and require sterilization by
means of heat. Semicritical items touch mucous
membranes or nonintact skin and have a lower
risk of transmitting infection. Most semicritical
items used in dentistry are heat tolerant and
should be sterilized before reuse.1,7
Noncritical items include clinical contact sur-
faces, such as bracket tables, countertops and
radiography equipment. Noncritical items have
the lowest risk of transmitting infection, be-
cause they contact only intact skin, which can
serve as an effective barrier to microorganisms.
The U.S. Environmental Protection Agency
(EPA) registers disinfectants used on noncritical
surfaces. In the absence of blood, health care
workers can disinfect surfaces using an EPA-
registered hospital-level disinfectant that does
not have a tuberculocidal claim. When blood is
visible, health care workers need to use an
intermediate-level disinfectant, which is one
with a tuberculocidal claim. Because it is often
difficult to see blood, the agent of choice for clin-
ical contact surfaces is an intermediate-level
disinfectant.1,8,9
Proper disinfection is a two-part process:
cleaning followed by disinfection. A single agent
usually can accomplish both tasks. Cleaning
reduces the number of contaminating microor-
ganisms, the amount of bioburden (such as
blood and saliva) and other adherent materials.
Disinfectants with good detergent action are
preferable. When organic materials are present
and not removed, they can insulate microorgan-
isms and decrease disinfectant activity.1,8,10
There are two approaches to cleaning fol-
lowed by disinfection. In the “spray-wipe-spray”
method, the surface is sprayed with a disinfec-
tant, wiped with a paper towel and sprayed
with disinfectant again. In the “wipe-discard-
wipe” method, the surface is wiped with a disin-
Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH
fectant wipe or towelette that is discarded, and
the surface is wiped again with a new wipe or
towelette.1,8,9
Although no perfect disinfectant exists, there
are a number of desirable characteristics for
such products.8-11 Use of the disinfectant should
result in the death of a wide variety of patho-
genic microorganisms without causing the
emergence of resistant forms. Disinfecting
action should be efficient and effective, even in
the presence of organic material. Exposure to
the disinfectant should not harm humans or the
environment. Modest cost, a pleasant odor and
an extended shelf life also are beneficial.
A disinfectant must have good antimicrobial
activity and at the same time have minimal
negative effects on the integrity of the surfaces
being disinfected. A disinfectant that causes the
surface to degrade could make the surface not
only esthetically unpleasing but also harder to
clean and disinfect across time. There is a
paucity of information in the literature con-
cerning the outcome of repeated contact be-
tween disinfectants and surfaces. Therefore, I
conducted a study designed to measure the
effect long-term disinfection had on common
types of dental office environmental surfaces.
METHODS
I tested nine common dental surfaces and six
spray disinfectants, as well as a tap water con-
trol. I used the spray-wipe-spray method with
paper towels to disinfect the surfaces. I con-
ducted blood removal testing of the surfaces to
measure the disinfectants’ cleaning ability.
Test surfaces. The nine types of surfaces I
chose as test samples were smooth vinyl; tex-
tured vinyl; brushed aluminum; smooth stainless
steel; laminated, heat-resistant thermosetting
plastic (Formica, Formica Group, Cincinnati);
service line rubber hosing; high-impact plastic;
acrylic resin sheets (Plexiglas, Altuglas Interna-
tional, Bristol, Pa.); and enameled metal. Each
surface-disinfectant pairing had 10 samples,
each being a 10-centimeter square at least 20
millimeters thick, except for the service line
rubber hosing, which was 15 cm long.
Disinfectants. The six disinfectants I chose
were Birex SE Concentrate (Biotrol, Earth City,
Mo.), CaviCide spray (Metrex, Orange, Calif.),
regular bleach (Clorox, Oakland, Calif.) diluted
1:10 with tap water, DisCide ULTRA Disin-
fecting Spray (Palmero Health Care, Stratford,
ABBREVIATION KEY. EPA: U.S. Environmental Pro-
tection Agency. MRSA: Methicillin-resistant
Staphylococcus aureus.
JADA 143(5) http://jada.ada.org May 2012 473
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
(Reckitt Benckiser, Parsippany, N.J.) and Opti-
Cide3 solution (Biotrol) (Table 1). I mixed the
Birex SE formulation with tap water according
to the manufacturer’s recommendations. Tap
water served as a nonchemical control.
The manufacturers of Birex SE, CaviCide,
DisCide ULTRA Disinfecting Spray and Opti-
Cide3 claim their products are surface cleaners
and disinfectants.12-14 The manufacturer of Lysol
Brand II IC Disinfectant Spray has specific dis-
infection claims about surfaces already
cleaned,15 and the manufacturer of the bleach
diluted 1:10 with tap water has nonspecific,
general antimicrobial claims.1 Although bleach
is not an EPA-registered product, the Centers
for Disease Control and Prevention considers
diluted household bleach (5.25 percent) an effec-
tive and inexpensive disinfecting agent.1
Spray disinfection. I used the standard
spray-wipe-spray method to disinfect the sur-
faces. I sprayed an average of 0.75 milliliters of
the disinfectant to cover each test surface
entirely. Using a c-fold paper towel, I wiped the
disinfectant up and down the surface 10 times. I
applied the disinfectant a second time to com-
plete disinfection. After the exposure time rec-
ommended by the manufacturer, I wiped the
surface with a second paper towel to remove any
residual disinfectant.
Experiment. I estimated, on the basis of dis-
infection of dental operatory clinical contact sur-
faces occurring 10 times per day in dental prac-
tices that are open four days per week for 48
weeks per year, that each surface is disinfected
1,920 times per year.
Repeated disinfection can lead to loss of or
change in surface integrity, which could affect
the efficiency of disinfection cleaning. Therefore,
before the first disinfection procedure and after
every 100 disinfection procedures, I tested the
surfaces by using a blood removal test. I covered
the center (1.0 square centimeter) of each sam-
ple with 0.1 mL of defibrinated sheep blood. I let
the thin film of blood dry for 60 minutes, and
then I disinfected the surface and obtained a
sample of it to test for residual blood.
To obtain samples to test for residual blood, I
rotated a single cotton swab moistened in saline
over the entire soiled area. I then placed the
swab into a tube containing 2.0 mL of saline and
vortexed it for 30 seconds. I tested for the pres-
ence of blood by using dipstick tests designed to
detect minute amounts of blood in urine
(Hemastix, Bayer, Leverkusen, Germany). After
60 seconds, I measured the color intensity by
comparing the results to a standard color chart
on the packaging. The small area on the stick
containing the reactive chemicals turned blue-
green if blood was present. Scores range from 0
to 6. A score of 0 indicates solutions containing
no red blood cells; a score of 6 indicates the
presence of 350 or more red blood cells.
Statistical analysis. I analyzed study
results by using a paired t test scheme (IBM
SPSS Statistics 19, IBM, Somers, N.Y.). The
risk level was .05 at a minimum. I analyzed dif-
ferences in test surfaces and disinfectants with
regard to blood removal test results.
A study with 10 samples per surface-
disinfectant pairing had an 80 percent power for
detecting a difference of at least 50 percent in
the percentage of samples with blood removal
change, according to a two-sided χ2 test with a
5 percent significance level. I used statistical
software (NCSS 2007, NCSS, Kaysville, Utah)
to calculate sample size.
RESULTS
The baseline scores in this study were the
cleaning scores I obtained when I used the con-
trol. I disinfected the surfaces by using the
standard spray-wipe-spray method. I tested all
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-
turers made only disinfection claims as opposed
to cleaning and disinfection claims.
Changes in sample surface integrity would be
due to the mechanical interaction of the paper
towel and the test surface in the absence of a
chemical disinfectant. The disinfection process
could make the test surfaces rougher or duller
or possibly buff them smoother. In either case,
the important factor was monitoring changes in
cleanability—whether it was easier or more dif-
ficult to remove blood.
Table 2 shows blood removal scores for the
nine test surfaces after 1,920 disinfection pro-
cedures had been performed for each surface-
disinfectant pairing. I found that, in general,
DisCide ULTRA Disinfecting Spray had the
highest blood removal scores (greatest amount of
residual blood). Diluted bleach and Lysol Brand
II IC Disinfectant Spray had similar scores.
Birex SE had the lowest overall blood removal
scores (least amount of residual blood) compared
with the other disinfectants. In some pairings,
the control had lower blood removal scores com-
pared with those of some of the disinfectants.
Smooth and textured vinyl, enameled metal and
service line rubber hosing were the most difficult
surfaces to clean at the end of the study because
of surface degradation.
To measure the ability of a disinfectant to
clean a standardized amount of blood off a sur-
face, I conducted t tests to compare initial
cleaning scores with those obtained after 1,920
disinfection procedures had been performed for
each surface-disinfectant pairing (Table 3). The
use of Opti-cide3 resulted in the fewest signifi-
cant differences, followed by the use of Birex
SE, which decreased blood removal significantly
on only one surface: enameled metal. The use of
the control resulted in decreased blood removal
on four of the surfaces (enameled metal; lami-
nated, heat-resistant thermosetting plastic;
acrylic resin sheets; and high-impact plastic).
Diluted bleach affected the surfaces the most
and resulted in statistically significant differ-
ences, indicating a decrease in blood removal on
all but two surfaces. The other three disinfec-
tants had results that varied according to the
type of surface that underwent disinfection.
DisCide ULTRA Disinfecting Spray had the
highest blood removal scores. Diluted bleach
and Lysol Brand II IC Disinfectant Spray had
similar scores, and Birex SE had the lowest
overall blood removal scores compared with
those of the other disinfectants. In some pair-
ings, the control had lower blood removal scores.
DISCUSSION
A decrease in a surface’s cleanability after being
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
action associated with wiping, as well as pos-
sible chemical effects resulting from surface-
disinfectant pairings could affect the removal of
surface contamination negatively.
The blood removal test involving 0.1 mL of
blood that I used to measure cleaning was
demanding. Dental office personnel should not
often encounter such amounts of blood. The
larger amount of blood used in this study, how-
ever, appeared to help differentiate the
cleaning actions of the disinfectants under
demanding circumstances. Disinfectants with
known good cleaning abilities appeared to have
the advantage.
Ideally, a disinfectant should produce results
that mimic those of water’s effect on the surface
across time. The effects of mechanical action
(repeated rubbing of surfaces with a paper
towel) should produce similar results. Differ-
ences in cleanability should come from exposure
to specific disinfectants. Birex SE had surface
integrity and blood removal results equal to or
in some cases better than those of the control.
The least effective disinfectant was diluted
bleach.
The study had limitations. Even though they
were representative, I tested only nine surface
types and six disinfectant agents with fixed
active agent concentrations and formulations.
Ten samples per group should have been suffi-
cient for statistical analysis. The relative
amount of blood used to soil each surface was
considerably more than that normally found on
dental office environmental surfaces. Finally,
the blood detection test was open ended. Al-
though the test was highly sensitive, a score of 6
indicted the presence of approximately 350 or
more red blood cells. I could not determine how
much higher the quantity of red blood cells was
by using the dipstick test.
CONCLUSIONS
I conducted this study to measure the effect
long-term disinfection had on common types of
dental office environmental surfaces. In general,
the repeated use of disinfection procedures
(even when using the control) resulted in sur-
face deterioration and increased difficulty in
blood removal. After comparing the test prod-
ucts’ results to the control’s results and ac-
knowledging the limitations of the study, I
found that Birex SE consistently had better
blood removal scores across time, which may
indicate that less surface deterioration occurred,
compared with those of the other disinfectants
and the control. DisCide ULTRA Disinfecting
Spray had the poorest blood removal results.
CaviCide and Opti-Cide3 had similar blood
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.

Brand II IC Disinfectant Spray had higher
blood removal scores.
After undergoing long-term disinfection,
some surfaces remained relatively easy to clean.
Other surfaces, such as enameled metal and the
smooth and textured vinyl surfaces, became
harder to clean. Perhaps the use of enameled
metal surfaces in dental offices should be min-
imal, or, as in the case of vinyl, it may be pru-
dent to use plastic protective barriers instead of
requiring the surfaces to undergo multiple dis-
infection procedures. ■
Disclosure. Biotrol (Earth City, Mo.) provided funding for this
study that included travel to meetings and author compensation.
Biotrol (Earth City, Mo.) provided financial support for and the
Birex and Opti-Cide3 products used in this study.
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