Initial Report
| Establishment under investigation (name and address) | Dr. George Chan Dentistry353 St. Paul Ave, Brantford, ON N3R 4N3 |
| Establishment type | Dental office |
| Date health unit became aware of potential IPAC lapse | October 29, 2025 |
| Date of initial report posting | November 17, 2025 |
| Date of initial report update(s) (if applicable) | |
| How was the IPAC lapse identified? | Complaint |
| Date of on-site investigation | November 3, 2025 |
IPAC Lapse Investigation
| Did the IPAC lapse involve a member of a regulatory college? | Yes; RCDSO |
| If yes, was the issue referred to the regulatory college? | Yes; RCDSO |
| Were corrective actions recommended and/or implemented? | All waterlines should be purged at the beginning of each workday by flushing them thoroughly with water for at least two minutes. Before purging is carried out, handpieces, air/water syringe tips, and ultrasonic tips should be removed from the waterlines. Install a dedicated eyewash fountain/station and ensure it is located within a 10-second walk (16 to 17 metres [55 feet]) of the reprocessing area. Maintain sterilizer logs which includes: load control label (sterilizer number, load number, and date of sterilization), chart/printout of physical parameters of the sterilization cycle, load contents, person responsible for the sterilization cycle, chemical indicator (CI) and biological indicator (BI) monitoring results. Conduct testing for sonification performance is required at least weekly or preferably each day it is used, using a commercial method or foil test in accordance with MIFU X-ray holders must be packaged for sterilization as per MIFU to maintain sterility until point of use. Clean supplies (x-ray film) and sterile items should be stored in an enclosed space such as cabinets or drawers. Pouring dental models, including mixing of dental stone should be done in an area away from instrument reprocessing to avoid contamination from stone powder. To prevent cross-contamination, new gloves should be worn when developing radiographic films. Gloves used in the operatory are considered contaminated and must be removed and discarded before handling film processing equipment. Hand hygiene should be performed, and clean gloves donned prior to film development in accordance with IPAC best practices and Public Health Ontario guidelines. Relocate unused sterilization pouches to a designated clean storage area, separate from the dirty area. Ensure the workflow allows staff to access pouches without re-entering the dirty area, reducing the risk of cross-contamination during instrument packaging. Obtain MIFUs for all reusable critical and semi-critical dental devices and instruments. Ensure that all critical and semi-critical reusable dental instruments in your office meet sterilization requirements in accordance with their MIFU. Store all contaminated containers, including sharps and dental scraps, in a designated area separate from clean supplies to prevent cross-contamination. Use an enzymatic cleaning solution for pre-cleaning of used and dirty dental instruments to ensure effective debris removal and consistent instrument reprocessing. If cleaning cannot be performed immediately, instruments should be placed in a puncture-resistant holding container and soaked with a detergent formulated for medical device reprocessing or an enzymatic cleaner to prevent drying of organic material, and make subsequent cleaning easier and less time-consuming. Ensure all hinged instruments are cleaned and sterilized in the open or unlocked position to allow proper steam penetration. Disassemble multi-component instruments prior to cleaning and sterilization, as per their MIFU, to ensure effective reprocessing. Organic matter may accumulate on brushes used for cleaning instruments. Cleaning brushes must be inspected frequently and discarded when worn or damaged. At the end of every day, cleaning brushes must be sterilized or discarded. Do not use bars of soap for manual cleaning of soiled dental instruments. Ultrasonic cleaners must be routinely tested for efficacy according to their MIFU. Perform testing at least weekly or each day it is used, using a commercial method or foil test. Ultrasonic Cleaner solution should be changed at least once daily to ensure optimal results. Use lint-free cloth to dry instruments. All critical and semi-critical instruments must be sterilized according to MIFUs and stored in their sterile packaging until the time of use. Reduce the number of instruments per pouch or use larger pouches to ensure adequate steam penetration and contact with all instrument surfaces Disassemble equipment consisting of multiple components prior to cleaning and sterilization, as per their MIFU. All hinged instruments should be cleaned and sterilized in the open or unlocked position to ensure proper steam penetration and effective sterilization. Each package must be labeled with the date reprocessed, sterilizer used, cycle or load number and healthcare workers initials. Do not write directly on the paper side of peel pouches. Obtain MIFUs for all reusable critical and semi-critical instruments for complete reprocessing instructions e.g. recommended cycle parameters. Verify and document cycle parameters are met after each load. Sterilizer is tested with a biological indicator (BI) in a process challenge device (PCD) each day the sterilizer is used and with each type of cycle used that day, as per PIDAC Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices in All Health Care Settings (3rd Edition). Refer to PIDAC Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices in All Health Care Settings (3rd Edition) for proper use of biological and chemical indicators. Do not use type 5 steam sterilization integrators that are past their expiration date. Develop and implement comprehensive written policies and procedures for reprocessing and IPAC, in accordance with current public health and regulatory guidelines. Ensure all staff are trained on and have access to your written IPAC policies and procedures. |
| Date of any order(s) or directive(s) issued to the owner/operator (if applicable) | November 3, 2025 |
| Summary description of the IPAC lapse | During the complaint inspection it was observed that the disinfection and sterilization of reusable instruments on site do not follow Provincial Infectious Disease Advisory Committee (PIDAC) Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices (May 2013). Lines in suction machine insufficiently flushed between clients. Semi-critical items (i.e., hand piece motors) not high-level disinfected or sterilized. Improper use of PPE noted, gloves insufficiently changed from operatory rooms to developing radiographic films. Improper storage of sterilized items (e.g., impression trays cleaned and sterilized, not stored in sterilized packages). Insufficient documentation of sterilization logs (logs do not include details on the load contents, the individual responsible for sterilization or the results of the B.I. and C.I. monitoring. Ultrasonic efficacy testing not being completed at time of visit. Ultrasonic cleaner solution currently being changed weekly. Laboratory work (i.e., impression pouring and x-ray development) observed to be conducted in reprocessing room. Activities that lead to creation of dust or debris should not be conducted in sterilization room to prevent contamination of sterile items. There is not a one-way workflow from dirty to clean to prevent cross contamination (e.g. sterilization pouches located in dirty area of reprocessing room). Dental equipment insufficiently reprocessed – tools consisting of multiple components were not disassembled according to the MIFU (e.g., two-piece mirrors), several hinged instruments (including forceps, needle drivers, and scissors) were also packaged in the closed position. Instruments are transported from operatory to reprocessing area wrapped in a paper tray cover. Transportation containers and enzymatic spray are not used. Clean and sterile instruments were observed to be stored loose and unpackaged in operatory rooms (mirrors, explorers, hand scalers, pliers, stainless steel syringes, dental burs, etc.) No biological monitoring being done, no biological indicators were on site for qualification or re-qualification of sterilizers. Sterile instrument packages were labeled with only the sterilization load number and contents written on the paper side of the pouch. Sterilized packages were observed to be stored tightly together with punctures. Cycle parameters of sterilizer were not verified after each load. |
| Additional comments and/or updates to initial report | Staff members responsible for any or all steps in reprocessing are recommended to complete the PHO modules for Reprocessing in Community Health Care Settings, and the Medical Device Reprocessing Techniques Online Course through the Medical Device Reprocessing Association of Ontario. |
Full Report
| Brief description of corrective measures taken | The dental office is permanently closed. A patient recall has been completed as part of the corrective actions. |
| Date all corrective measures were confirmed to have been completed | The dental office permanently closed on November 3, 2025, and a patient recall was initiated in March 2026. |
| Date of final report posting and/or any date of any updates to final posting | March 18, 2026 |
| Date of follow-up to confirm corrective actions taken and completed | November 3, 2025 |