Presented by Dr.

Aishwarya Hajare
1st year post graduate student

1
Contents-
 INTRODUCTION
 TERMINOLOGIES
 HISTORY
 CLASSIFICATION
 DETAILS OF INDIVIDUAL AGENTS
 BIOLOGICAL CONTROLS
 STERILIZATION IN DENTISTRY
 STERILIZATION IN PERIODONTICS
 INFECTION CONTROL
 WASTE MANAGEMENT
 RECENT ADVANCES IN STERILIZATION AND DISINFECTION
 CONCLUSION
 REFERENCES

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Introduction
 Microorganisms are ubiquitous.

 Since pathogenic microorganisms cause contamination,

infection and decay, it becomes necessary to remove or
destroy them from materials and areas.

 This is the objective of infection control and sterilization.

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 STERILIZATION Sterilization (or sterilisation) is a term referring to any
process that eliminates or kills all forms of life and other biological
agents including transmissible agents (such as fungi, bacteria, viruses, prions,
spore forms, unicellular eukaryotic organisms such as Plasmodium, etc.) present
in a specified region, such as a surface, a volume of fluid, medication, or in a
compound such as biological culture media.

( WHO Glossary )

 STERILE: Free from all living microorganisms; usually described as a

probability (e.g., the probability of a surviving microorganism being 1 in 1
million).(CDC guidelines 2008)

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 DISINFECTION: Destruction of pathogenic and other kinds of
microorganisms by physical or chemical means. Disinfection is less lethal
than sterilization, because it destroys the majority of recognized pathogenic
microorganisms, but not necessarily all microbial forms (e.g., bacterial
spores).(CDC guidelines 2008)

 Disinfection is a process of removing or killing most, but not all, viable

organisms.

MIMS-PLAYFAIR,5th

5
 ANTISEPSIS is the prevention of infection, usually by
inhibiting the growth of bacteria in wounds or tissues

 BACTERICIDAL AGENTS: Those which are able to kill

bacteria.

 BACTERIOSTATIC AGENTS: Only prevents the

multiplication of bacteria which may however remain alive.

 DECONTAMINATION: The process of rendering an article

or area free of danger from contaminants, including microbial,
chemical, radioactive and other hazards.

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History of sterilization
 Hippocrates of Cos (460-377 BC), was the first to separate medicine from
philosophy and disproved the idea that disease was punishment for sin. He
also advocated irrigation of wounds with wine or boiled water,
foreshadowing asepsis.

 Ignaz Semmelweis, an Hungarian obstetrician, advocated in 1847 the value

of handwashing and fingernail scrubbing.

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 In 1862, French chemist and microbiologist
Louis Pasteur publishes his findings on how
germs cause disease, which he later uses to
develop the pasteurization process.

 Joseph Lister, an English physician, reduced the

mortality rate of his patients in 1867 by using a
carbolic solution spray as he operated, he then
used it in the wound.

 Charles Chamberland, Louis Pasteur’s pupil

and collaborator, developed the first pressure
steam sterilizer, or autoclave in 1876.

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 The research of Robert Koch and his associates in 1881 on the disinfecting
properties of steam and hot air mark the beginning of the science of
disinfection and sterilization. They devised the first non pressure flowing
steam sterilizer.

 Aesculap created the first rigid instrument container, originally made of

stainless steel, in Germany. In the early 1900’s, responding to the needs of
the military hospitals and aid stations, Aesculap manufactured chrome-plated
containers for safe transport of sterile instruments..

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METHODS OF STERILIZATION AND DISINFECTION

PHYSICAL METHODS CHEMICAL METHODS

• SUNLIGHT • ALCOHOLS
• DRYING • ALDEHYDES
• DRY HEAT • DYES
• MOIST HEAT • HALOGENS
• FILTRATION • PHENOLS
• RADIATION • SURFACE-ACTIVE
• ULTRASONIC AND SONIC AGENTS
VIBRATIONS • METALLIC SALTS
• GASES

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PHYSICAL AGENTS

 Sunlight:- Active germicidal effect due to the combined effect of U.V and heat
rays. e.g.:- river, tanks & lakes.

 Drying:- 4/5ths of weight of bacterial cell consist of water and hence drying has
a deleterious effect on many bacteria.
 Heat :- most reliable and commonly applied way of sterilization
Dry heat
 Flaming:- Inoculating loops or wires, the tip of
forceps & needles and spatulas are held in a bunsen
flame till they become red hot in order to be
sterilized.

 Incineration :- Rapidly destroying materials such as

soiled dressings, bedding, animal carcasses,
pathological materials etc.

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DRY HEAT

Principle-

- Protein denaturation.

- Oxidative damage.

- Toxic effects of elevated levels of

electrolytes.

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HOT AIR OVEN:-

 It’s the most widely used mode of sterilization

 Temp.- 160°C ( 320° F ) for 1-2 hr.

 Uses :-
- Glasswares like glass syringes, petridishes, flasks,
pipettes & test tubes.

- Surgical instruments like scalpels, scissors, forceps

etc..

- Chemicals such as liquid paraffin, fats, greases,

Sulphonamide, dusting powder etc. 13
 Precautions:-
1) Not to be overloaded.
2) Must be fitted with fans for even distribution of
hot air.
3) Materials to be sterilized should be perfectly dry.
4) Rubber materials (except silicone rubber) will
not withstand the temperature.
5) Allowed to cool for 2 hrs before opening the
doors.
Advantage: Disadvantage :
Economical. Hot air is bad
conductor of heat
Does not rust metals hence it has less
penetrating power
Easily monitored .

Used for anhydrous

oils & powder. 14
 MOIST HEAT

• pasteurisation of milk.
TEMPERATURE • Inspissation.
BELOW 100O C • Vaccine bath.
• Low temperature steam formaldehyde.

• Boiling
TEMPERATURE • Tyndallisation
AT 100O C • Steam sterilizer at 1000 C

TEMPERATURE • Autoclave
ABOVE 100O

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 AUTOCLAVING
Boiling water alone is INSUFFICIENT to kill spores and viruses

water boils when its vapour pressure equals to that of surrounding atmosphere

Hence, when pressure increases inside closed vessel

Temperature at which water boils increases

saturated steam has penetrative power

When steam comes in contact with a cooler surface it condenses to water

and gives up latent heat to that surface. The large reduction in volume of steam
sucks in more steam to the site and the process continues till the temperature of
article is raised to that of steam.
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 AUTOCLAVE

 Three major factors for effective autoclave:

1. Pressure: 15psi.
2. Temperature: 121oC
3. Time: 15 mins.
 Higher temperature and pressure require shorter time
for sterilisation.

Pressure (psi) Temperature Time (mins)

(°C)
• 15 • 121 • 15
• 20 • 126 • 10
• 20 • 134 •3

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 Types of autoclave
DOWNWARD DISPLACEMENT
 Also known as Gravity displacement unit.
 This is because of the method of air removal in the sterilization
chamber.

POSITIVE PRESSURE DISPLACEMENT

 It’s an improvement over downward displacement autoclave.
 Steam is created in a second, separate chamber and held until the
proper amount to displace all of the air in the sterilization
chamber is accumulated.
 The steam is then released into the sterilization chamber in a
pressurized blast, forcing the air out through the drain
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hole and
starting the sterilization process
NEGATIVE PRESSURE DISPLACEMENT

 one of the most accurate types of unit available

 Once the sterilization chamber door is closed, a vacuum pump removes

the air.

 Steam is created in a second, separate chamber.

 Once the air has been completely removed from the sterilization
chamber, the steam is then released into the sterilization chamber in a
pressurized blast much like that of a positive pressure displacement unit.

 The negative pressure displacement unit is able to achieve a high

"Sterility Assurance Level" (SAL), but the system can be quite large and
costly.
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TRIPLE VACUUM AUTOCLAVE

 A triple vacuum autoclave is set up/function in a

similar fashion to a negative pressure displacement.

 This is repeated three times, hence the name "triple

vacuum" autoclave. This type of autoclave is suitable
for all types of instruments and is very versatile

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 Classification of a autoclave

Classification Suitable for Processing Used by

N Type (Downward Unwrapped solid

Displacement) instruments for immediate
use.
S Type (Vacuum) Items specified by the Medical Surgeries
autoclave manufacturer. Podiatrist
N.B. Eschmann units Tattooist
suitable for naked and Body Pierces
single wrapped solid and
hollow items.

B Type (Vacuum) Unwrapped & wrapped Dentists

solid and hollow Plastic surgeons
instruments. Porous loads, Day surgeries
e.g drapes & gowns.
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Considerations during autoclaving
1. Ensure complete air removal for temperature
to reach 121°C.

2. Ensure loose packing in the chamber.

3. Tightly sealed materials may become

dangerously pressurized causing injury when
removed.

USES:
Disposable syringes, Non disposable syringes,
Glassware, Metal instruments, surgical dressing,
Surgical instruments, Laboratory equipment, Culture
media, Pharmaceutical products. 22
 Advantage:- Disadvantage:-

Economical. Moisture retention

Good penetration. Causes corrosion

Carbon steel gets

Short cycle time. damaged

Easily monitored Dulling of unprotected

cutting edges.

No special chemicals
or exhaust required. Destruction of heat
sensitive materials.
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Filtration helps to remove bacteria from heat labile such as sera and solutions of
sugars or antibiotics used for preparation of culture media.

Candle Filter Asbestos Filter

Sintered Glass Filters Membrane Filters

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 RADIATION

1) Non-ionising radiation:
 Uses longer wavelength and lower energy. And hence lose
the ability to penetrate substances, and can only be used for
sterilizing surfaces
 Eg. infrared radiation is used for rapid mass sterilization of
prepacked items eg. Syringes, catheters.
 UV radiation is used for disinfecting enclosed areas like
operation theaters, laboratories.

2) Ionising radiation:
 Uses short wavelength, high-intensity radiation with high
penetrative power to destroy microorganisms.
 This radiation can come in the form of gamma or X-rays
that react with DNA resulting in a damaged cell.
 Since there is no appreciable increase in the temperature, it
is also known as COLD STERILIZATION.
 Used for sterilizing plastics, swabs, metal foils etc. 25
Gamma radiation
 The Nature of Gamma Radiation -A form of pure energy that is
generally characterized by its deep penetration and low dose rates,
Gamma Radiation effectively kills microorganisms throughout.
 Benefits of Gamma Radiation include:
1. precise dosing
2. rapid processing
3. uniform dose distribution
4. system flexibility
5. dosimetric release–the immediate availability of product after
processing.
 Penetrating Sterilization: Even with High-Density Products Gamma
Radiation is a penetrating sterilant.
 Substantial Decrease in Organism Survival: Gamma Radiation kills
microorganisms by attacking the DNA molecule. 26
ULTRASONIC and SONIC CLEANING

 More effective than manual cleaning.

 Removes dried serum, whole blood, plaque, zinc phosphate
and polycarboxylate cements from instruments, metal
surfaces and dentures.
 Minimizes handling of contaminated instruments.
 During cleaning, totally submerge instruments in the
ultrasonic solution for 2 to 20 minutes .
 Ultrasonic solution should be changed atleast once a day.

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 Flash sterilization

 “Flash” steam sterilization was originally defined by Underwood

and Perkins as sterilization of an unwrapped object at 1320C for 3
minutes at 27-28 lbs. of pressure in a gravity displacement
sterilizer.
 Currently, the time required for flash sterilization depends on the
type of sterilizer and the type of item (i.e., porous vs non-porous
items).
 Uses:
- Flash sterilization is considered acceptable for processing cleaned
patient-care items that cannot be packaged, sterilized, and stored
before use.
- It also is used when there is insufficient time to sterilize an item by
the preferred package method.
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BIOLOGICAL CONTROLS FOR DIFFERENT
STERILIZATION METHODS

METHOD OF BIOLOGICAL CONTROL

STERILIZATION

Hot Air Oven Bacillus subtilis subsp. Niger

Clostridium tetani

Autoclave Bacillus stearothermophilus

Filtration Serratia marcescens,

Pseudomonas diminuta

Ionizing Radiation Bacillus pumilis 29

 CHEMICAL AGENTS

LIQUIDS GASES
• Alcohols • Formaldehyde
• Aldehydes • Ethylene Oxide
• Phenols • Plasma
• Halogens
• Heavy Metals
• Surface Active Agents
• Dyes

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 Protein coagulation

 Disruption of the cell membrane

 Removal of the free sulphydryl groups

 Substrate competition

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Critical
instruments
Penetrate the soft tissue
 Contact the bone
 Enter into or contact the
blood stream
They should be
thoroughly cleaned and
heat sterilized if they are
to be reused.
Eg: Surgical instruments,
Scalers, Scissors
Surgical dental burs
Scalpel blades
Forceps
Bone grafts
CLASSIFICATION
OF INSTRUMENTS
Semi-critical Non-critical
Instruments Instruments
 Contact the mucous  Come into contact
membrane but will not with intact skin
penetrate the soft
tissue
Eg : X-Ray tubes, Light
Eg : Mouth mirror, handles, Counter tops
impression trays,
handpieces, probe,
tweezers
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33
 ALCOHOL

Mechanism of Action : Denaturation of Proteins

 Isopropyl alcohol
Used as a skin
 70% ethyl alcohol disinfectant

 Ethyl alcohol is active against the fungal

spores and used to treat cabinets and
incubator
 Suitable for skin preparation before
venepuncture

Disadvantage : . Inflammable
. Mucous membrane irritant.
. Promotes rusting.
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 ALDEHYDES

A)Formaldehyde (formalin)
In aqueous solution it acts as a bactericidal and sporicidal
Active against Gram -ve bacteria, spores, viruses (HB, HIV) & fungi

Aqueous soultion: Formalin(37% solution) - 10% formalin +

0.5% Na tetraborate used to clean metal instrument e.g.
Endoscope, dialysis equipment.

Gaseous form: Fumigation of wards/corridors/ICU’s

DISADVANTAGE: Have pungent odour & irritating effect on

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skin & mucous membrane.

B.GLUTARALDEHYDE / CIDEX ( 2% alkaline NaHCO3)

 High level disinfectant

 Especially active against tubercle bacilli,f ungi

and viruses

 Less toxic than formaldehyde

 Can be safely used to treat corrugated rubber

anaesthetic tubes, face masks, metal instruments.

 Exposure time: > 10hrs.

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PHENOLS:
Acts by cell membrane damage thus releasing cell contents and
causing lysis

 Eg. Cresol ( LYSOL) ,chlorhexidine ( SAVLON),chloroxylenol

(DETTOL)

 Phenol is commonly found in mouthwashes, scrub soaps and

surface disinfectants

 Low efficiency disinfectant

 Used for decontamination of the hospital environment, including

laboratory surfaces, and noncritical medical items.

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HALOGENS :

A) Chlorine compounds:

 Bleaching powder or hypochlorite solution

mostly used disinfectant for HIV infected
material.

 in concentration of 0.05 or 0.5% used for

surface material and instruments disinfection

 Should be prepared daily because of

instability of sodium hypochlorite solution

 Active against bacteria, spores, fungi and

viruses (HB, HIV) 38
B) IODOPHORS & IODINE
 Active against bacteria, spores & some
viruses & fungi

 Suitable for skin preparation, mouthwash &

as a surgical scrub
(7.5% Povidone+iodine= Betadine)

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 SALTS

 Salts of heavy metals have toxic effect on bacteria.

 The salts of copper , silver and mercury are used as disinfectant.

SURFACE ACTIVE AGENTS

 substances which alter energy relationships at

interfaces,producing a reduction of surface tension, are known as
surface active agents. E.g. quaternary compounds

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 ETHYLENE OXIDE

• Highly inflammable and in concentration more than 3% highly

explosive and hence not used for fumigation of rooms

• Mix with carbon dioxide or nitrogen to eliminate its explosive

tendency

• Effective against all types of micro-organism including

viruses and spores.

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 RECOMMENDED CONCENTRATIONS

DISINFECTANT CONCENTRATI
ON

Ethyl Alcohol 70%

Gluteraldehyde 2%
Lysol 2.5%
Savlon 2%
Dettol 4%
Bleaching powder (Calcium hypochlorite) 14 gm in 1 L water

Sodium hypocholorite 1%, 0.1%

Betadine (Iodophore) 2%
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STERILISATION AND
DISINFECTION IN
DENTAL CLINIC

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The four accepted methods of sterilization in dental offices
are:

 Steam pressure sterilization (autoclave)

 Chemical vapor pressure sterilization(chemiclave)

 Dry heat sterilization(dryclave)

 Ethylene oxide(ETOX) sterilization

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Steam pressure sterilization(autoclave)
 It is performed in a steam autoclave. For light load of instruments
the time required at 121o C is 15 minutes at 15lbs of pressure. It
works on principle as that of pressure cooker.

Advantages: rapid and effective.

Disadvantages: items sensitive

Tends to rust carbon steel instruments and burs.

Sterilization of burs in autoclaves.

burs can be protected by keeping them submerged in small amounts

of 2% sodium nitrite solution.
45
Chemical vapor pressure sterilization

 Performed in a chemiclave.

Operate at 131oC and 20lbs of pressure. they are similar to steam

sterilizer and have cycle of 30minutes.

• carbon steel and other corrosion sensitive instruments and pliers

are sterilized without rust or corrosion.

• items sensitive.

The 1938 patent of Dr. George Hollenback and the work of

hollenback and harvey in 1940s culminated in the development of
an unsaturated chemical vapor system , also called harvey
46
chemiclave.
 Advantages Disadvantages

1. Carbon steel and other 1. Items sensitive to the

corrosion-sensitive elevated temperature will be

instruments are said to be damaged. Vapor odor is

sterilized without rust. offensive, requires aeration.

2. Relatively quick turnaround 2. Heavy cloth wrappings of

time for instruments. surgical instruments may not

be penetrated to provide
3. Load comes out dry.
sterilization.
4. Sterilization is verifiable.

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Dry heat sterilization

 Conventional dry heat ovens

 Short cycle, high temperature dry heat oven.

They have heated chambers that allow air to circulate by gravity flow.

A rapid high temperature processing that uses forced draft oven(air circulates with a

fan or blower)

Operate at approximately 188oC-191oC

48
Advantages Disadvantages
1.Reasonable price 1.rubber and plastic materials

2. carbon steel instruments and might damage.

burs do not rust or corrode or lose 2. heavy load of instruments

temper or cutting edges. defeats sterilization.

3. Rapid cycles possible at high 3. Improper calibration may

temperatures damage instruments

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Ethylene oxide sterilization
Etox sterilization is the best method for sterilizing complex
instruments and delicate materials.
Advantages
 Operates effectively at low temperatures
 Gas is extremely penetrative
 Can be used for sensitive equipment like handpieces.
 Sterilization is verifiable
Disadvantages
 Potentially mutagenic and carcinogenic.
 Requires aeration chamber ,cycle time lasts hours
 Usually only hospital based.

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 OPERATORY ASEPSIS
 In the dental operatory, operatory surfaces that are
repeatedly touched or soiled are best protected with
disposable covers(barriers)that can be discarded after
each treatment.

 For dental unit trays, paper, plastic film or surgical pack

wraps (paper or towels) should cover the entire tray.

 Clear plastic 15-gallon waste container bags fit many

chair backs , control units , and x-ray equipment.

 Plastic restaurant silverware bags it suction handles and

air water syringe handles.
51
 Gigasept which contains succindialdehyde and
dimethoxytetrahydrofuran are used for disinfection of
plastic and rubber materials eg: dental chair

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Asepsis of surgery theaters
 Fumigation is done by two methods:

1. Electric boiler method- 500 ml of formaldehyde

(40%) added to distilled water in electric boiler.
When the water heats fumes are generated.

2. Potassium permanganate – heat is induced by

oxider action of potassium permanganate. 500ml
of formaldehyde is added to potassium
permanganate which reacts and generates fumes.

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DENTAL RADIOGRAPHY
CDC(MMWR),dec19,2003vol.52

• Contamination of working area occurs from saliva.

• X-ray tube head, exposure selector and timer button are likely to get
contaminated by saliva.

• Precaution to be taken up :

1. Put on gloves.

2. Place the film packets and film holders in special tray.

3. Contaminated films(exposed films) to be placed in separate tray.

54
4. Film holding device to be rinsed in running water to remove
saliva.

5. Metallic part to be autoclaved.

6. Plastic attachments to be kept in chlorhexidine solution.

7. Wipe the x-ray tube head, exposure selector, timer button and film
packets with detergents.

8. Tube can be wrapped in disposable plastics.

9. Film packets to be discarded in yellow bags.

55
 BIOPSY SPECIMEN
CDC(MMWR),dec19,2003vol.52

• Biopsy collection & transportation can also be a source of

infection.

• It should be kept in sturdy containers with secure lid.

• Avoid contaminating the external surface of the container.

• Swab used for collecting micro-organisms should be

transferred slowly and carefully to the swab container.

56
• BIO-FILMS :

CDC(MMWR),dec19,2003vol.52

• Tubes connecting hand-pieces, air/water syringe &

ultrasonic scaler unit are harbor of wide range of
micro-organisms.

• They colonize and replicate on the inner surface of

tubings.

• They serve as reservoir for micro-organisms.

57
Following measures should be taken to prevent this :

A) Anti-retraction valves : (one way flow check valve). To prevent

transfer or aspiration of potentially infected material in the tubings.

B) Bacterial filter : Filters to be fitted in water lines of hand-pieces &

water syringes.

C) Chemical Disinfectants : Tubings are flushed with disinfectants like

sodium hypochlorite.

D) Aspirators : Cleaned and flushed after every patient for 20 – 30

secs.

To be flushed with disinfectant at the end of the day.

58
 Impression trays are sterilized as follows
metallic - autoclave
plastic – ethylene oxide

 Disinfection of alginate impressions –

Methods
- Spraying
- Immersion
Iodophors, sodium hypochlorite (1:10 concentration ) ,
phenols, formaldehyde, glutaraldehyde.
59
 DENTAL CASTS
CDC(MMWR),dec19,2003vol.52
 Spraying until wet or  ADA recommends use of
Immersing in a 1:10
 Chlorine compounds
dilution of sodium
hypochlorite or an  Iodophors
iodophor then rinse  Combination of synthetic
 Casts to be disinfected phenols
should be fully set (i.e.  Glutaraldehyde.
stored for at least 24
hours)

60
• Sterilize instruments like articulators, wax knives, spatula, shade
guide, acrylic bur etc.

• Custom impression trays, base plates, occlusal rim and all other
prosthesis must be disinfected, after construction & before use in
patient.

• Articulators, casts, base plates to be disinfected by 1:10 chlorine

solution following each session or before returning to laboratory.

• Dentures washed & soaked in sodium hypochlorite for 5 mins before

delivery.
61
 ROTARY INSTRUMENTS - BURS

 Diamond and carbide burs:

After use they are placed in 0.2%
gluteraldehyde and sodium phenate (Eg.
Sporicidin) for at least 10 minutes,
cleaned with a bur brush or in an ultrasonic
bath.
Sterilize in an autoclave or dry heat

 Steel burs:
May get damaged by autoclaving. Can be
sterilized by using a chemical vapor sterilizer or
glass bead sterilizer at 2300C for 20-30 seconds.

62
 ENDODONTIC INSTRUMENTS
CDC(MMWR),dec19,2003vol.52
• Glass Bead or salt sterilizer is the best option, but they do not
sterilize the handle.

• Sterilization achieved in 10 seconds

• Dry heat is used, with instruments in closed metal or perforated

metal boxes.

• Sterilization achieved at 218oC for 15 seconds

• Gutta percha points are pre-sterilized.

• Contaminated points are sterilized by 5.25% sodium

hypochlorite.(1 min immersion).

• Then rinse with hydrogen peroxide & dry it. 63

• Silver cones sterilized by passing slowly over the flame for
3-4 times.

• Can also be sterilized in hot salt sterilizer.

• Files to be handled with tweezer.

• Glass slab is sterilized by swabbing the surface with

tincture of thiomersal, followed by swabbing with alcohol.

• Cement spatula is sterilized by flamming 3 or 4 times over

bunsen flame.

64
HANDPIECE SURFACE
CONTAMINATION CONTROL

65
 IMPLANTS
 Pre sterilized with Gamma radiation
 In case the implants needs to be re-sterilized conventional
sterilization techniques are not satisfactory
 Steam sterilization should not be used as it results in contamination
of surfaces with organic substances
 Dry heat sterilization also leaves organic and inorganic surface
residue
 Radio frequency glow discharge technique (RFGDT) or Plasma
cleaning is used.
 In this, material to be cleaned is bombarded by high energetic ions
formed in gas plasma in a vacuum chamber.
 Removes both organic and inorganic contaminants.

66
Sterilization in periodontal clinic
 All diagnostic instruments are sterilized by washing in korsolex and
sterilized.
 Periodontal instruments
SHARP
e.g. knives,
scissors,
Files
Tissue holding forceps
BLUNT
Mouth mirrors,
tweezers,
artery forceps,
suture holding forceps 67

Periosteal elevator
 Sharp instruments are ideally sterilized by :
conventional hot air oven

by not sterilized:
 Boiling
 Autoclave
 2% glutaraldehyde

 Blunt instruments are sterilized by

 Autoclave

68
Sutures
 Sutures are pre sterilized by gamma radiation
 Sutures are re- sterilized by two recommed methods are
1. Soak for a full 10 minutes completely immersed in
povidone iodine 10% solution, then rinse in sterile
saline/water.
2. Ethylene Oxide – gas sterilisation.

 Sterilising/disinfecting by other methods (autoclaving,

boiling, alcohol-soaking) are not recommended.
Glutaraldehyde has been taken off the market since May
2002. It was never intended to be a suture soaking solution
due to its high toxicity and the inability to ensure that all the
solution is rinsed off before use
69
 ULTRASONIC SCALERS
CDC(MMWR),dec19,2003vol.52

 Soak inserts in a container containing 70% isopropyl alcohol for

removal of organic debris.
 Rinse cleaned inserts thoroughly in warm water to remove all
chemicals. As a final rinse, replace the insert into the scaler
handpiece and operate the scaler for 10 seconds at the maximum water
flow setting to flush out any retained chemicals
 Dry inserts completely with air syringe
 Package in proper wrap, bags, pouches, trays, or cassettes. Add spore
tests and chemical indicators.
 Ethylene Oxide is the preferred method of choice
 Dry heat and chemical vapor methods of sterilization are considered
ineffective methods with risk of damage to materials as per American
Dental association Supplement to J.A.D.A. 8/92.
70
Effect of sterilization on
instruments
Sterilization Type of instrument

Stainless steel Carbon steel

Saturated steam at 250°F Amorphous substance Dulling and oxidation of
formed near cutting edge; cutting surfaces
no dulling.
Formalin-alcohol vapor at Cracking of wire edge; no Some oxidation of
270°F dulling. surfaces; no dulling.
Dry heat at 320°F Chipping of wire edge; no No visual change.
dulling.
Dry heat at 340°F Chipping of wire edge; no No visual change
dulling.
Effects of Sterilization on Periodontal
Instruments Roger B. Parkes,* and Robert A.
Kolstadf Accepted for publication 31 August
71
1981
Recent advances in sterilization and
disinfection
 Various new methods of sterilization are under investigation and
development.

 Peroxide vapor sterilization - an aqueous hydrogen peroxide

solution boils in a heated vaporizer and then flows as a vapor into
a sterilization chamber containing a load of instruments at low
pressure and low temperature

 Ultraviolet light - exposes the contaminants with a lethal dose of

energy in the form of light. The UV light will alter the DNA of
the pathogens. Not effective against RNA viruses like HIV.

72
Plasma Sterilization
 Plasma is basically ionized gas. When you apply an
electric field to a gas, it gets ionized into electrons and
ions.

 Plasma is usually comprised of UV photons, ions,

electrons and neutrals.

 A plasma is a quasi-neutral collection capable of

collective behavior

 Their combined photolytic, chemical and electric

action efficiently kills most micro-organisms.
Ozone
 Ozone sterilization is the newest low-temperature
sterilization method recently introduced in the US and is
suitable for many heat sensitive and moisture sensitive or
moisture stable medical devices

 Ozone sterilization is compatible with stainless steel

instruments.

 Ozone Parameters • The cycle time is approximately 4.5

hours, at a temperature of 850F – 940F.

74
 Newer Disinfectants
 Persistent antimicrobial-drug coating that can be applied to inanimate and
animate objects containing silver (Surfacine)

 A high-level disinfectant with reduced exposure time (ortho-

phthalaldehyde)

 An antimicrobial drug that can be applied to animate and inanimate objects

(superoxidized water)
 INFECTION AND
INFECTION
CONTROL

67
76
 BASIC CONCEPT OF INFECTION CONTROL

 Prevent spread of infection from the Clinician to

the patient

 Prevent the spread of infection from the Patient

to the Clinician

 Prevent the spread of infection from one patient

to another

Patient

Other
Operator
67 personnel 77
 For routine dental examination procedures, hand washing is achieved
by using either a plain or antimicrobial soap and water.

 The purpose of surgical hand antisepsis is to eliminate transient flora

and reduce resident flora to prevent introduction of organisms in the
operative wound, if gloves become punctured or torn.

 At the beginning of a routine treatment period, watches and jewelry

must be removed and hands must be washed with a suitable cleanser.

 Hands must be lathered for at least 10 seconds, rubbing all surfaces and
rinsed.

 Clean brushes can be used to scrub under and around the nails.

 Must be repeated at least once to remove all soil.

78
79
80
81
  Hegde et al in their study stated that the bar soap under
the "in use" condition is a reservoir of microorganisms
and washing hands with such a soap may lead to
spread of infection. (Microbial contamination of "in
use" bar soaps in dental clinics. Indian J Dent Res
2006;17:70-3)

67
82
Methods of hand drying

83
 HOW TO WEAR
SURGICAL GLOVES

84
 Masks
 Types:

1. Surgical masks (required to have

fluid-resistant properties).

1. Procedure/isolation masks

 Made up from a melt blown placed between non-woven fabric

Layers of a Mask

1. an outer layer

2. a microfiber middle layer - filter large wearer-generated particles

3. a soft, absorbent inner layer - absorbs moisture.

 Available in 2 sizes: regular and petite.

85
N95 PARTICULATE RESPIRATOR

 National Institute for Occupational Safety and

Health (NIOSH) introduced a rating system which
identifies the abilities of respirators to remove the
most difficult particles to filter, referred to as the
most penetrating particle size (MPPS), which is
0.3µm in size.
 The “N” means “Not resistant to oil”.
 N95: captures at least 95% of particles at MPPS.
 N99: captures 99% of particles at MPPS.
 N100: captures 99.97% of particles at MPPS.

86
When should I wear an N95
respirator?

N95 particulate respirator 87

Eye wear

 CAUSES OF EYE DAMAGE:

1. Aerosols and spatter may transmit infection

2. Sharp debris projected from mouth while using air turbine

handpiece, ultrasonic scaler may cause eye injury.

3. Injuries to eyes of patients caused by sharp instruments

especially in supine position
88
 Over garments
Gown type Situation and Rationale

Cotton/linen, reusable or disposable, long- Use if contamination of uniform or clothing is

sleeved isolation gowns likely or anticipated

Fluid resistant isolation gown or plastic apron
over isolation gown
Use if contamination of uniform or clothing
from significant volumes of blood or body fluids
is likely or anticipated (fluids may wick through
non-fluid resistant reusable or disposable
isolation gowns)

Fluid impervious gowns e.g., Gortex®
Use if extended contact or large volume
exposure (e.g., large volume blood loss during
resuscitation of MVA victim
89
or surgical assist)
Footwear

 Most hospitals have their own policies regarding footwear.

 Footwear with open heels and/or holes across the top can
increase the risk of harm to the person wearing them due to
more direct exposure to blood/body fluids or of sharps being
dropped for examples.
90
 OCCUPATIONALLY ACQUIRED INFECTIONS

 HIV : 0.3%

 Hepatitis C : 1.8%

 Hepatitis B (HBeAg +ve) : 30%

 Occupational exposures that may result in HIV, HBV,

or HCV transmission include needlestick and other
sharps injuries; direct inoculation of virus into
cutaneous scratches, skin lesions, abrasions, or burns;
and inoculation of virus onto mucosal surfaces of the
eyes, nose, or mouth through accidental splashes

 All health care professionals should be immunized

against Hepatitis A, Hepatitis B, Varicella, MMR, DPT,
Rubeola, Meningitis, Polio, Influenza, Tetanus,
67 Diptheria, Rubella.
91
Post exposure prophylaxis-HIV

 Wound care:
 Clean wounds with soap and water
 Flush mucous membrane with water.
 No evidence of benefit for: – application of antiseptics or
disinfectants
– squeezing puncture sites

 Chemoprophylaxis
 Initiating occupational 4 week regimen of PEP
(zidovudine+ lamivudine+nevirapine)as soon as
possible, ideally within 2 hours of exposure.
 HIV- antibody testing should be performed for atleast 6
months post exposure
67 92
HIV Infection Control
(OSHA regulations)

• Measures at the time of Surgery :

• Proper hand washing.
• Surgical attire for operation theater.
• Cover the operation table with waterproof &
disposable sheet.
• Patient to be posted at the end of the operation list.
• Staff with laceration or abrasion on their hands are
excluded from the theatre.

93
• Number of staff member to be kept minimum.
• Separate members outside the operation theater for fetching the
drugs, equipments etc.
• Disposable foot covers, caps, mask, plastic gowns and protective
eye wear.
• Wearing of double gloves.
• Face mask or cap, if contaminated with splatter of blood, should
be replaced immediately.
• Scissors & diathermy should be used instead of blade or
scalpels.

94
• Sharp instruments not to be handed directly, but to be
delivered via kidney tray.
• Patient allowed to recover in operation theater instead of
recovery room and directly transferred to ward.
• In case of spillage of blood or body fluid, it should be
moped up using gloves and old linen/paper towel or news
paper.
• Sent for incineration in plastic bag.
• Area to be covered with 1% sodium Hypochlorite.
• Floor is wiped with soap and water followed by 1% sodium
hypochlorite.

95
• Gloves removed at last after removing mask, cap and
gowns.
• All sharp instruments kept in puncture proof plastic
container.
• Proper labeling done & sent for incineration.
• Needles to be capped before shredding.
• Non sharp waste kept in large plastic bag, labeled and
sent for incineration.
• Reusable instruments autoclaved.
• Then washed with soap and water.
• Re-autoclaved.

96
• Non-autoclavable instruments immersed in 2%
glutaraldehyde solution for 1 hour.
• Then cleaned with warm water and detergents.
• Again soaked in glutaraldehyde for 3 hours.
• Suction bottle should contain 30 ml of 2%
glutaraldehyde or 60 ml of 1% sodium hypochlorite.
• It is carefully emptied out, rinsed and autoclaved after
surgery.
• Ventilator tubes rinsed in running tap water and
immersed in 2% glutaraldehyde for 2 hours.

97
• Laboratory specimen placed in 10 % formalin jar,
with tight leak proof cork.
• It is kept in a bag and tightly closed and sealed, before
transportation to laboratory.
• Operating table, floor and walls to be thoroughly
cleaned with 1% sodium hypochlorite.
• Equipments or surfaces that cannot be easily
disinfected are covered with aluminium foil or
disposable plastic covers during surgery.

98
• Measures for Health Care workers (OSHA regulations)

A proper staff education and training.

Vaccination of all employees.
• Universal precautions to be observed.
• Proper hand washing.
• Careful handling of sharp objects & instruments.
• Proper sterilization, disinfection or disposal of
instruments after use.
• Use of gloves, mask, gowns etc.

99
PRINCIPLES AND PROCEDURES FOR HANDLING
AND CLEANING INSTRUMENTS AFTER
TREATMENT
 The safest and most efficient instrument cleaning procedures
involve ultrasonic cleaning of used instruments kept in a
perforated basket or cassette throughout the cleaning
procedure.
 Used instruments are commonly placed in an anti microbial
solution as this softens and loosens debris.
 Next, move the instruments or basket of instruments into an
ultrasonic cleaning device, rinse them, and then carefully
inspect the instruments for debris.
 instruments likely to rust , dip into a rust inhibitor solution.
Drain & dry instruments with absorbent towel.
100
101
INSTRUMENT PROCESSING

ADA guidelines for

sterilization

102
 Effect of sterilization on
instruments
Sterilization Type of instrument

Stainless steel Carbon steel

Saturated steam at 250°F Amorphous substance Dulling and oxidation of
formed near cutting edge; cutting surfaces
no dulling.
Formalin-alcohol vapor at Cracking of wire edge; no Some oxidation of
270°F dulling. surfaces; no dulling.
Dry heat at 320°F Chipping of wire edge; no No visual change.
dulling.
Dry heat at 340°F Chipping of wire edge; no No visual change
dulling.
Effects of Sterilization on Periodontal
Instruments Roger B. Parkes,* and Robert A.
Kolstadf Accepted for publication 31 August
103
1981
 Waste management

• Divided into two categories :

A) Bio-hazardous materials.
B) Non-bio-hazardous materials.
A) Bio-hazardous materials consist of waste materials :
– 1. Soaked with blood or other body secretions.
– 2. Capable of causing infectious disease.
– 3. Having a poisonous effect.
– 4. Human tissue removed during surgery.
– 5. Teeth and associated tissues.
– 6. Gloves.

104
• B) Non-bio-hazardous materials consist of waste materials :
– 1. Matrix bands.
– 2. Masks, caps, gloves, patient’s napkin’s.
– 3. Impression materials.
– 4. X- ray packets & surface covers.

105
 Waste Management

 Categories of bio-medical waste in india

Options Waste category

Category 1 Human anatomical

waste(tissues
,organs,body parts)
Category 2 Animal waste
Category 3 Microbiology and
biotechnology waste
Category 4 Waste sharps
(needles,syringe,sca
lpels…)
Category 5 Discarded medicine
67 106
and cytotoxic drugs
Waste Management
Category 6 Solid waste(items contaminated
with blood and fluid including
cotton dressing….)
Category 7 Solid waste (waste generated
from disposable items )
Category 8 Liquid waste(waste generated
from laboratory and washing
cleaning …)
Category 9 Incineration ash
Category 10 Chemicals used in production of
biological, chemical used in
disinfection

67 107
COLOUR CODES
COLOUR TYPE OF WASTE TREATMENT
CONTAINER CATEGORY OPTIONS

YELLOW PLASTIC BAGS Human and animal Incineration,

wastes, Microbial deep burial
and
Biological wastes
and soiled
Wastes, eg. human
tissues, body
parts, organs,
lab cultures,
specimens,
items
contaminated
with blood
RED DISINFECTED Microbiological and Autoclave,
CONTAINER/PLAS Biological wastes, microwave,
TIC BAGS Soiled wastes, chemical burial
Solid waste,
eg.
Disposable 108

items like
catheters, IV
COLOUR CODE TYPE OF WASTE TREATMENT
CONTAINER CATEGORY OPTIONS
BLUE/WHITE PLASTIC Waste sharps Autoclave/
TRANSPARENT BAG,PUNCTURE and solid waste, Microwave
PROOF eg. .Sharps, /
CONTAINER needles , Chemical
scalpels, Treatment
disposable Destructio
items like n
catheter, IV set
etc

BLACK PLASTIC BAG Discarded DISPOSAL IN

medicines, SECURED LAND
incinerated FILLS
ashes,
chemicals used
for disinfection
etc. 109
 CONCLUSION
 A steady increase in the serious transmissible diseases over the
last few decades have created a global concern and impacted the
treatment mode of all health care practitioners.

 Emphasis has now expanded to assuring and demonstrating to

patients that they are well protected from risks of infectious
disease.

 The dental health care provider has to follow high standards of

infection control for the safety of the patients and the dental
health care workers

67 110
References
 Texbook of microbiology by Prof. CP Baveja.(3rd edition)
 Operative dentistry chp- infection control by
Studervant.(4th edition)
 Essentials of preventive and community dentistry Soben
peter (3rd edition)
 Textbook of clinical periodontology, Newman, Takei,
Carranza, 11th edition.
 WHO glossary
 Article on Sterilization of Suture material by Ingrid Cox
dated 2004 17(50) from Community Eye Health Journal.
 Article on effects of sterilisation on periodontal instruments
by Roger B. Parkes and Robert A. Kolstadf Accepted for
publication 31 August 1981 Journ Periodont
111
 Article on recent advances in sterilization by William
A.Rutala and David Weber( Emerging Inectious Diseases
 Sterilization and disinfection of dental instruments by ADA
 Disinfection & sterilization of dental instruments TB MED
266, 1995
 CDC, guidelines for disinfection & sterilization in health
care facilities 2008.
 Infection prevention and control, college of respiratory
therapists Ontario, june 2011
 New CDC guidelines for selected infection control
procedures, chris miller.
 CDC guidelines for infection control in dental health care
settings, Dec19, 2003/vol.52.
 Sterilization of ultrasonic inserts

112