INFECTION CONTROL

CONTENTS
• Introduction
• Types of contamination
Air borne contamination
Direct and indirect contamination
• Cross infection
• Occupational Safety and Health Administration—Required
• Personal Barrier Protection
• Disposal of clinical waste
• Overview of Aspteic techniques
• Operatory Asepsis
• Sterlization
• References
INTRODUCTION
❏ For most of the twentieth century, general dentistry was routinely
practiced without barriers to protect eyes, nose, mouth, and hands .
❏ Not until 1991 were dental personnel required to wear gloves,
masks, gowns, and protective eyewear while treating patients.
❏ Microbial exposures in the dental operatory include air-borne
contamination and direct and indirect contamination of surfaces.
Air borne contamination

• A high-speed handpiece is capable of creating air-borne contaminants

from bacterial residents in the dental unit water spray system and from
microbial contaminants from saliva, tissues, blood, plaque, and fine
debris cut from carious teeth
• With respect to size, these air-borne contaminants exist in the form of
Spatter
Mist
Aerosols
Aerosols consist of invisible particles ranging from 5 mm to
approximately 50 mm that can remain suspended in the air and
breathed for hours.
● Aerosols and larger particles may carry agents of any respiratory infection
carried by the patient.
● No scientific evidence indicates, however, that fine aerosols have
transmitted the blood-borne infection caused by hepatitis B virus (HBV).
● Transmission of human immunodeficiency virus (HIV) by aerosols is even
less likely
Dentistry as it may have been practiced in the past. Rotary
instrumentation can expose personnel to heavy spatter of more
than 50-mm particles and mists. Aerosol particles of less than 5
mm remain suspended and can reach the alveoli if not stopped
by a barrier. Air purification is a growing concern. (Courtesy of
Laminaire Corporation, Palm Beach Gardens, FL.)
Mists that become visible in a beam of light consist of droplets
estimated to approach or exceed 50 mm. Heavy mists tend to settle
gradually from the air after 5 to 15 minutes
Spatter consists of particles generally larger than 50 mm and even
visible splashes.
. Spatter has a distinct trajectory, usually falling within 3 feet (ft) of the
patient’s mouth, having the potential for coating the face and outer
garments of the attending personnel.
. Spatter or splashing of mucosa is considered a potential route of
infection for dental personnel by blood-borne pathogens
• Direct contamination
1. Direct contamination occurs during direct contact with bodily fluids,
and this is a major exposure concern for dental personnel.
• Indirect contamination
1. With saliva-contaminated hands, the hygienist, the dentist, and the
assistant could repeatedly contact or handle unprotected operatory
surfaces during treatments.
2. The invisible trail of saliva left on such contaminated surfaces often
defies either awareness or effective cleanup.
3. Soiled surfaces that are poorly cleaned provide another sourse of
gross environmental contamination and thus potential cross
contamination of personnel and patients
CROSS INFECTION
Cross-infection is transmission of infectious agents among patients and staff
within a clinical environment. This source of infection can be:
• Patients suffering from infectious diseases
• Patients who are in the prodromal stage of infections
• Healthy carriers of pathogens
Different Routes of Spread of Infection
 Patient to Dental Health Care Worker
• Direct contact through break in skin or direct contact with mucous
membrane of DHCW
• Indirect contact via sharp cutting instruments and needle stick injuries
• Droplet injection by spatter produced during dental procedures and through
mucosal surfaces of dental team
Dental Health Care Worker to the Patient
• Direct contact, i.e. through mucosal surfaces of the patient.
• Indirect contact, i.e. via use of contaminated instrumentsand lack of use of
disposable instruments
• Droplet infection via inhalation by the patient
Patient to Patient
• It occurs by the use of contaminated and non disposable instruments.
Dental Office to the Community
It occurs:
• When contaminated impression or other equipment contaminate dental
laboratory technicians
• Via spoiled clothing and regulated waste.
Community to the Patient
• Community to the patient involves the entrance of microorganisms into
water supply of dental unit.
• These microorganisms colonize inside the water lines and thereby form
biofilm which is responsible for causing infection
• Patient Vulnerability
• Although infection risks for dental patients have not been as well
investigated as risks of hospital patients, they seem to be low.
• Nine cluster cases of dentist-to-patient transmission of hepatitis B virus (HBV)
and one cluster case of HIV have been documented since 1971.
• Since 1986, when infection control practices became widespread, no cluster
cases of HBV transmission related to dentistry have been reported
• Personnel Vulnerability
• When dental personnel experience exposure to saliva, blood, and possible
injury from sharp instrumentation while treating patients, they are more
vulnerable to infections if they have not had the proper immunizations or
used the proper protective barriers.
• It is unfortunate that the need for proper control of exposures and infections
was not realized before the occurrence of the blood-borne HBV infection,
which poses a serious threat to all dental personnel
• Transmission of occupational disease from the patient to the dental health
care worker is low
• Regulations Regarding Infected Health Care Personnel
• All health care personnel who perform invasive, exposure prone
treatments are urged to obtain testing for HBV and HIV infections
voluntarily
• Clinical personnel are considered infected when they test positive for
antibodies against HIV or for hepatitis B surface antigen (HBsAg) and
hepatitis Be antigen (HBeAg).
• Infected health care personnel are advised not to perform exposure-prone
procedures unless they have sought counsel from an expert review panel
• As defined by the CDC, a review panel may consist of the worker’s
physician, an infectious disease specialist with expertise in the
epidemiology of HIV and HBV transmission, another health care
professional with expertise in the type of procedures performed, and a
local public health official
Occupational Safety and Health Administration—Required

AIDS Infection
• AIDS is the last stage of a
debilitating, eventually fatal human
disease.
• AIDS may develop in 1.5 to 11 or
more years after an initial infection
with HIV
• HIV is a relatively fragile ribonucleic
acid (RNA) retrovirus, which is easily
destroyed in the dry state in 1 to 2
minutes by most disinfectants
• Symptoms and Oral Manifestations
• Within 3 months of infection, temporary flu-like symptoms— pharyngitis,
myalgia, fatigue, fever, or diarrhea—may occur when antibodies to HIV
become detectable
• During examination, the dentist can easily detect one or two cervical lymph
nodes, especially below the mandible, that persist for more than 3 months.
• The nodes may be attached and painless, or they may be movable, painful,
and infected.
• Undifferentiated non-Hodgkin’s lymphoma may arise in lymph nodes or may
appear in the mandible, central nervous system, eyes, bone marrow, and
other vital organs
• Persistent oral candidiasis is often seen with easily dislodged, white, curd-
like patches scattered over the tongue
Human Immunodeficiency Virus Risks for Clinical Personnel
• Of all health care workers injured by needles and sharp instruments used
to treat HIV-infected persons, only 0.3% or less have become infected with
HIV.
• This statistic contrasts with 30% of workers who become infected with HBV
after parenteral exposure to infected blood.
• Dental personnel have been spared, almost miraculously, being infected
with HIV.
• Patients seriously ill with AIDS who are seen in a hospital setting also may
harbor transmissible respiratory infections such as tuberculosis and
cytomegalovirus (CMV) infection
• Transmission of drug-resistant tuberculosis from
immunocompromised patients is a growing concern.
• Personnel without adequate barrier protection should avoid
exposure to coughing, saliva spatter, and heavy aerosols from HIV-
infected persons with signs of respiratory infection. This applies
especially to pregnant women because recent infection with CMV
can be detrimental to the fetus
Human Immunodeficiency Virus risks for Dental Patients
• With proper use of infection control measures in dental practice, the risk for a
dental patient of contracting HIV from office personnel or from other patients is
extremely low.
• In a circumstance that has been unique as of 2011, six patients were found to be
infected with the same strain of HIV present in a Florida dentist who had treated
[Link] is quite likely that some kind of clinician- to- patient transmission had
occurred in this case
Human Immunodeficiency Virus Data Related to Infection Control
• Very low levels of HIV usually have been found in the blood of infected persons.
This is especially true of asymptomatic persons
• HIV was detected in only 28 of 50 samples of blood from infected persons. In saliva
from infected persons, HIV was detectable in only 1 of 83 samples
• CDC investigators have found 99% of HIV to be inactive in approximately 90 minutes
in dried infected blood
• HIV is killed by all methods of sterilization. When used properly, all
disinfectants, except some quaternary ammonium compounds, are said to
inactivate HIV in less than 2 minutes.
• HIV has been transmitted through blood-contaminated fluids that have been
heavily spattered or splashed on persons.
• Barriers have proved successful in protecting dental personnel in hospital
dentistry and in all other dental clinics against HIV
Viral Hepatitis Infection: Symptoms and
Clinical Findings
• HBV must enter the circulating blood to
reach the liver, where the viral DNA causes
infected hepatic cells to reproduce the
virus.
• Symptoms usually appear after 2 to 4
months of incubation. Extensive liver
damage and illness occur rapidly in
approximately 2 of 10 infected persons.
• Symptoms and signs include nausea,
vomiting, chronic fatigue, mental
depression, fever, joint pain, darkened
urine, jaundice, elevated liver enzymes, and
possibly diarrhea or rash
Hepatitis B and Hepatitis C Virus Infection Risks for Personnel

• Personnel can be infected through parenteral exposure; mucosal exposure to

infected blood or blood-contaminated saliva; and spatter of infected blood to the
eyes, mouth, or broken skin.
• Paper cuts from blood-contaminated request forms have been reported to have
transmitted [Link] saliva also can be weakly infectious.
• Aerosolized, blood- contaminated saliva and respiratory secretions that can
transmit many respiratory viruses and tuberculosis have not been shown to
transmit HBV.
• One in three parenteral exposures of non-vaccinated personnel to HBV-infected
blood has resulted in HBV infection
• HCV exposure risks for dental personnel have been documented and appear to be
low. Infection control should minimize risks.
• Data indicate that infection rates from parenteral exposure to HCV-infected blood
fall between the rates for HBV and HIV infection—approximately 1.8%
Data Related to the Control of Hepatitis B Virus
• HBV is a relatively stable virus that can withstand drying on surfaces and
presumably on equipment and clothing for more than 7 days.
• One billion virus particles of HBV can be found per mL of infected blood.
• Disinfectants selected for their ability to inactivate tuberculosis and
hydrophilic viruses seem to be able to inactivate HBV. All forms of sterilization
destroy the virus.
COVID 19
• COVID-19 has a mean incubation period of 5.2 days
• The infection is acute without any carrier status.
• Symptoms usually begin with nonspecific syndromes, including fever, dry
cough, and fatigue. Multiple systems may be involved,including respiratory
(cough, short of breath, sore throat,rhinorrhea, hemoptysis, and chest
pain), gastrointestinal(diarrhea, nausea, and vomiting), musculoskeletal
(muscle ache),and neurologic (headache or confusion)
• More common signs and symptoms are fever (83%–98%),cough (76%–82%),
and short of breath (31%–55%). Therewere about 15% with fever, cough,
and short of breath.
• Conjunctival infection was not reported in the early series andcases with
age under 18 were few
DIAGNOSIS
• The COVID-19 usually presents as an acute viral respiratory tract infection
and many differential diagnoses related to common viral pneumonia should
be considered, such as influenza, parainfluenza, adenovirus infection,
respiratory syncytial virus infection, metapneumovirus infection, and atypical
pathogens, such as Mycoplasma pneumoniae and Clamydophila
pneumoniae infections etc.
• Therefore, it is crucial to trace the travel and exposure history when
approaching a suspected patient back from an epidemic area
Safety protocol for dental patients
during the COVID-19 pandemic
PERSONAL BARRIER PROTECTION
1. Barrier protection of personnel using masks, protective eyeware, gloves, and
gowns is now a standard requirement for dental procedures.
2. Barrier protection of personnell and equipment instrument steralization and
methods of avoiding direct contact with various surfaces are mandateory
• Instructions for hand washing
1. At the begining of routine treatment the clinician should remove his or her
wrist watch, jwellery and rings then wash hands with suitable cleanser.
2. Hands should be lathered for atleast 15 seconds rubbing all surfaces and
rinsed.
3. Hand cleansers containing a mild aniseptic such as 3%
parachlorometaxlylinol or chlorexidin pereferable for controling transeant
pathogens and for supressing over growth of skin bateria.
4. Hand cleansers with 4% chlorexidin may have border activity for
special cleancing. Eg:- For surgery when gloves leak or when a clinician
expereiences an injury.
5. Additionally proper use of alcohol rubs is affective against
pathogens and less drying to hands.
.
GLOVES
• Regulations specify that all clinical personnel must wear treatment gloves
during all treatment procedures.
• After each appointment, or whenever a leak is detected, gloves are removed,
hands are washed and fresh gloves are donned
• Gloves must not be washed or used for more than one patient
• Used gloves should be disposed of carefully to avoid contaminating others in
the box
• While cleaning and sorting used sharp instruments, puncture-resistant utility
gloves should be worn. Nitrile latex gloves are preferable
• The concern among dental health care workers is based on the frequent
changes of gloves, which exposes them to the latex protein allergens.
Currently, no cure for latex allergy [Link] more than one patient
Protective Eyewear,Masks,and Hair
protection
• Protective eyewear may consist of
goggles or glasses with solid side-
shields.
• Face shields are appropriate for
protection against heavy spatter, but a
mask still is required to protect against
aerosols that drift behind the shield.
• The clinician should put on eyewear
with clean hands before gloving and
remove it with clean hands after the
gloves are removed. whenever
eyewear or shields are removed,they
should be cleaned and disinfected
• Remove if the mask as shown ,grasp the mask ties or elasticband behind the head instead of grasping the contaminated
mask .Before treatment put on maks and eyewear before washing and gloving hands .After treatment remove gloves and then
eyewear and mask and wash hands

re
• When the patient is dismissed after
treatment, the mask should be
discarded and not worn around the
neck
• Touching masks and eyewear during
treatments should be avoided to
prevent cross-contamination.
• When eyewear or shields are
removed, they should be cleaned and
disinfected
• To protect against aerosols,the edges
of the rectangular mask should be
pressed close around the bridge of
the nose and face
Protective overgarments
• An overgarment must protect clothing as well as skin . Used overgarments
should be only minimally handled and laundered or disposed of properly.
• Sleeves with knit cuffs that tuck under the gloves are preferable. If not covered,
arms must be washed after each patient if any spattering occurred
• Before leaving the clinical area, used overgarments are removed and placed
directly into a laundry bag with a minimum of handling or sorting
• Persons handling soiled clinical garments must wear protective gloves.
• Laundering with a regular cycle with regular laundry detergent is considered
acceptable, following manufacturer’s directions. Hot water (70°C or 158°F) or
cool water containing 50 to 150 parts per million (ppm) of chlorine provided by
liquid laundry bleach would provide additional antimicrobial action.
Disposal of clinical waste
• Infected blood and other liquid clinical waste, except mercury, silver, or other heavy
metal chemicals, generally can be poured down a sanitary sewer or drain designated
for that purpose.
• Application of aseptic precautions and cleaning and disinfection of the basin around
the drain must be performed.
• Contaminated materials such as used masks, gloves, blood- soaked or saliva-soaked
sponges, and blood-soaked or saliva- soaked cotton rolls must be discarded safely
• As pathologic waste, excised tissues require separate disposal and should not be
discarded into the trash.
• Care must be exercised in bagging medical waste so that injury or direct contact
with liquids does not occur, as HIV and HBV can survive beyond a few days in wet
blood
• Separating needles and sharps into hard-walled, leak-proof, and sealable containers
and out of soft trash has been shown to provide adequate safety.
Needle Disposal
• The goals with regard to needle
disposal are
• disposing of needles in a hard-
walled, leak-proof, and sealable
container
• locating the needle- disposal
container in the operatory close to
where the needle will be used
• avoiding carrying unsheathed
contaminated needles or containers
in a manner that could endanger
others or would allow the needles to
be accidentally spilled.
Precautions to Avoid Injury Exposure
• Pointed instruments without a hollow lumen have minimal capacity to
transmit infected blood into a puncture site. The same principles that apply
to needles should be to used burs, wires, and sharp instruments
• Sharp and curved ends should be turned away from the recipient’s hand
• A needle sheath holder or other safety device or technique should be used
for the operator to resheath the needle with only one hand.
• Burs should be removed from handpieces when the procedure is finished; if
left in the handpiece in a hanger, the bur should be pointed away from the
hands and body
• Hanging handpieces upside down in some types of hangers can angle the
bur away from the operator.
OVERVIEW OF ASEPTIC TECHNIQUES
• The concept of asepsisis to prevent cross contamination all items that are
touched with saliva coated hands must be the rendered free of contamination
before begining treatment on the next patient.
• These contaminated items can be discareded protected by disposable covers
or removed, cleaned and steralized.
• A few simple rules that help avoid wasting costly time and effort between
patient appointments are:-
“DO’S & DONT’S OF INTRUMENT RECYCLING”
• DO’S:
• Wear protective puncture resistenat gloves to handle used
intruments.
• Keep instruments wet in an anti-bacterial solution bfore cleaning.
• Use ultrasonic cleaning device.
• Test and maintain the ultasonic device periodiccaly.
• Use Good quality strealizer equipment
• Read the operator manual and follow operation instruction for
steralizing.
• Have steralizers annually inspected regarding gaskets, timer, valves
and temperature and pressure gauges
• Use proper water or chemicals to operate, clean, and maintain sterilizer.
• Place only dry instruments in the sterilizer.
• Use a wrap that will be penetrated by the steam or gas used. Load the
sterilizer loosely; leave air space between large packs. Read the sterilizer
temperature and pressure gauges daily.
• Use the complete sterilizer monitoring system outlined; use indicators daily
and spore tests weekly.
• Keep a record of daily indicators and spore tests
• Don’t:
• Place wet instruments into any type of sterilizer unless so instructed.
• Overwrap cloth packs or use impermeable wraps for steam or chemical vapor
pressure sterilization.
• Use closed, non-perforated trays, foil, canisters, or other sealed containers in
gas or steam sterilizers.
• Overload or cram packs together in the sterilizer.
• Decrease the required time for sterilization.
• Add instruments to a sterilizer without restarting the cycle. Sterilize viability
control strips supplied with spore tests
• Disinfectants
• Disinfectants must be active against the Mycobacterium species
and inactivate polioviruses or coxsackieviruses common respiratory
viruses, and common bacterial hospital pathogens (e.g.,
Staphylococcus and Pseudomonas species)
• Disinfectants containing 70-79% ethyl alchol are considered the most effective
disinfectant on cleaned surfaces
• sterilants used for high level disinfection of items
Regarding disinfection, two principles should be remembered:
(1) Disinfection cannot occur until fresh disinfectant is reapplied to a thoroughly
cleaned surface
(2) Disinfection does not sterilize
PROCEDUCERES & MATERIALS AND DEVICES FOR CLENING INSTRUMENTS BEFORE
STERALIZATION
• The instruments that touch mucosa or penetrate tissues must be cleaned and
steralized before use.
• ULTRASONIC CLEANSERS AND SOLUTIONS
• Ultrasonic cleaning is the most safest and most efficient way to clean sharp
instruments and it can be 9 times more effictive than hand cleaning.
• An ultrasonic cleaning device should provide fast and thurough cleaning without
damage to instruments: Have a lid, well designed basket and an audible timer.
• Procedure for ultrasonic cleaning as follows:
1. Observe operating precautions
2. operate the tank at one half to 3/4th full of cleaning solution at all times
3. Use only cleaning solutions recommended by the manufacturer of ultra sonic
device, change solutions as directed. An anti-microbial cleaning solution is
preferable.
4. Operate the ultra sonic cleaner for
5 min or longer as directed by
the manufacturer to acheive
optimal cleaning possibly 1min per
instrument.
5. Remove coating such as plaster,wax,
cement and impression material with
an appropriate solvent cleaner, and
place the instruments or impression
trays in a beaker in the ultrasonic
device
INSTRUMENT CONTAINMENT
• Various kinds of instrument trays and
cassettes are manufactured to contain
the instruments chairside,and they can
be place din an ultrasonic
cleaner,rinsed,and packaged ready for
sterilization
• Cassettes provide convenience,safety in
handling and cleaning batches of
instruments,and maintenance of
instrument organization for efficient use
OPERATORY ASEPSIS
Protection of Operatory Surfaces
• White paper sheets (“white newsprint”) are useful for workbenches and
operatory surfaces on which dry contaminated materials are placed.
• For dental unit trays, paper, plastic film, or surgical pack wraps should cover
the entire tray, including edges.
• Clear-plastic bags are available that fit many chair backs, control units, x-ray
equipment, suction handles, and air-water syringe handles
Preparation of Semi-Critical Items (Attached to the Dental Unit for Reuse) and
Noncritical Items (Supporting or Environmental)
• Instruments that come in contact with cut tissues or that penetrate tissues
are considered critical items that require thorough cleaning and sterilization
for reuse.
• Many items attached to the dental unit are used intraorally. They are handled
by gloved hands coated with blood and saliva or may touch the mucosa. CDC
guidelines consider these semi-critical items.
• Items that are not usually touched during treatments are considered non-
critical items.
CATEGORY DEFINITION EXAMPLES METHOD OF
HANDLING
CRITICAL Where instruments Surgical blades and • To be discarded
enter or penetrate instruments, whenever possible
into Surgical • Sterilized after
sterile tissue, cavity dental bur every use
or
blood stream
SEMI CRITICAL Which contact intact Amalgam condenser, • Sterilized after
mucosa or nonintact Dental every
skin handpiece,Mouth use
mirror, Saliva • High level of
ejectors disinfection
NON CRITICAL Enviromental surface Pulseoximeter,Steth To be disinfected
which oscope,Light between
contacts intact skin switches,Dental every patient
chair
SEMI-CRITICAL ITEMS
• Semi-critical items that touch mucosa are the air-water syringe tip, suction tips and
handpieces
• Others (air- water syringe handle, suction hose ends, lamp handle, and switches) are
handled or touched interchangeably with treatment instruments that become
contaminated with blood and saliva.
• Semi-critical items must be removed for cleaning and sterilization unless they are
disposable or can be protected from contamination with disposable plastic covers.
This applies especially to air-water syringe tips.
• Semi-critical items should not be merely disinfected. As stated before, they should
be covered, cleaned, and sterilized, or they should be discarded.
• Some bacteria often remain even after the use of the best [Link] a cover
comes off, or when disinfection is the only recourse, semi- critical items must be
scrubbed clean, preferably at the sink, and disinfected
• Surface disinfection is inadequate for items with a lumen, such as air-water syringe
tips.
NONCRITICAL ITEMS
• Noncritical items are environmental surfaces such as chairs, benches,floors,
walls, and supporting equipment of the dental unit that are not usually
touched during treatments
• Contaminated non-critical items require cleaning and disinfection
• One should wear protective utility gloves to clean equipment that cannot be
covered. For cleaning and disinfecting environmental surfaces, nitrile latex
utility gloves are preferable.
• Disinfectants can penetrate treatment gloves to irritate covered skin, and
these less sturdy gloves are prone to small tears.
• Uncovered chair arms may become contaminated with spatter and should be
covered with a protective barrier or disinfected. Areas of the chair not
contaminated by spatter need not be disinfected except for housekeeping
purposes
STERILIZATION
• Sterilization is defined as killing all forms of life ,including the
most heat resistent forms,that is bacterial [Link] most
instruments contact mucosa or penetrate tissues,it is essential to
be cleaned and sterilized
• The four accepted methods of sterilization are as follows:
1. Steam pressure sterilization (autoclave)
2. Chemical vapor pressure sterilization (chemiclave)
3. Dry heat sterilization (dryclave)
4. Ethylene oxide (ETOX) sterilization
 Steam pressure
sterilization[Autoclave]
• Sterilization with steam under pressure is performed in a steam
autoclave
• For a light load of instruments, the time required at 250°F (121°C) is a
minimum of 15 minutes at 15 lb of pressure. Time for wrapped
instruments can be reduced to 7 minutes if the temperature is
increased to approximately 273°F (134°C) to give 30 lb of pressure.
• Bench models may be automatic or manually operated. Manual
sterilizers should have a temperature and pressure gauge so that
temperatures can be related to corresponding pressure required for
sterilization.
• In contrast to hospital autoclaves, bench models depend on gravity
flow to distribute steam throughout the load, rather than first
evacuating air from the sterilizer and refilling it with steam. Bench
models require more caution against the use of large or tightly
packed loads.
• Steam must enter and circulate around packs easily. Instrument
pans or other impermeable instrument containers must be left open
so that steam can enter. Except for containers of solutions, all metal
items must be dry. Moisture evaporating from instruments can slow
the heating process
A steam pressure sterilizer (autoclave). (Courtesy of Midmark Corp., Versailles, OH.
ADVANTAGES OF AUTOCLAVING
• Autoclaving is the most rapid and effective method for sterilizing cloth
surgical packs and towel packs. Other methods are not suitable for processing
cloth packs.
• Automated models are available, although they can be misused; they must
be evaluated with a biologic .spore test monitoring system.

DISADVANTAGES OF AUTOCLAVING
• Items sensitive to the elevated temperature cannot be autoclaved.
• Autoclaving tends to rust carbon steel instruments and burs.
• Steam seems to corrode the steel neck and shank portions of some diamond
instruments and carbide burs
• Autoclave Sterilization of Burs
• For autoclave sterilization, burs can be protected by keeping them submerged in a
small amount of 2% sodium nitrite solution
• After ultrasonic cleaning, burs can be rinsed and placed into any small metal or glass
beaker with a perforated lid (e.g., a metal salt shaker)
• The beaker should be filled with sufficient fresh nitrite solution, with the level of the
solution approximately 1 cm above the burs. The container is left uncovered, or a
perforated cover is used.
• The container of burs and fluid is placed into the sterilizer, and a normal sterilization
cycle is operated. The fluid from the container is discarded through the perforated lid
• Sterile forceps should be used to place the burs into a sterilized bur holder or tray.
The burs are stored dry. Before use, any nitrite residue can be wiped away or rinsed
off with clean or sterile water, if desired
• Endodontic files sterilized by autoclaving in an instrument box at 121°C for 15
minutes at a pressure of 15 pounds
CHEMICAL VAPOR PRESSURE
STERILIZATION (CHEMICLAVING)
• Sterilization by chemical vapor under pressure is performed in a
chemiclave . Chemical vapor pressure sterilizers operate at 270°F
(131°C) and 20 lb of pressure.
• They are similar to steam sterilizers and have a cycle time of
approximately 30 minutes.
• Newer models seem to handle aldehyde vapors well; vapors from
older models must be safely vented. Water left on instruments loaded
into the chamber can prevent sterilization
ADVANTAGES OF CHEMICLAVING
• Carbon steel and other corrosion-sensitive burs, instruments, and pliers are said to
be sterilized without rust or corrosion.
DISADVANTAGES OF CHEMICLAVING
• Items sensitive to the elevated temperature are damaged.
• Instruments must be lightly packaged in bags obtained from the sterilizer
manufacturer.
• Towels and heavy cloth wrappings of surgical instruments may not be penetrated
to provide sterilization.
• Biologic spore test monitoring strips need to be used routinely to confirm heat
penetration of heavy packs before using them .
• Only fluid purchased from the sterilizer manufacturer can be used. Only dry
instruments should be loaded, and the door gasket should be checked for leaks to
avoid frequent sterilization monitoring failures
DRY HEAT STERILIZATION
Conventional Dry Heat Ovens

• Dry heat sterilization is readily achieved at temperatures greater than

320°F (>160°C).
• Conventional professional dry heat ovens that have been sold for
instrument sterilization have heated chambers that allow air to
circulate by gravity flow (gravity convection).
• Packs of instruments must be placed at least 1cm apart to allow
heated air to circulate. Individual instruments must be heated at
320°F (160°C) for 30 minutes to achieve sterilization
Short-Cycle, High-Temperature Dry Heat Ovens

• A rapid high-temperature process that uses a forced-draft sterilization

chamber (a mechanical convection sterilization chamber that circulates
heated air with a fan or blower) is available.
• It reduces total sterilization time to 6 minutes for unwrapped instruments and
12 minutes for wrapped instruments .
• These short-cycle, high-temperature dry heat sterilizers operate at 375°F
(190°C). The chamber size of one brand is limited to processing about one set
of instruments at a time but is more effective for wrapped instruments and
may be adapted for a shorter heat disinfection cycle
COX Rapid Heat brand rapid heat transfer dry heat sterilizer. (Courtesy of CPAC Equipment Inc., Leicester,
NY).
Advantages of Dry Heat Sterilization
• Carbon steel instruments and burs do not rust, corrode, or lose their temper
or cutting edges if they are well dried before processing.
• Industrial forced-draft hot air ovens usually provide a larger capacity at a
reasonable price. Rapid cycles are possible at high temperatures.
Disadvantages of Dry Heat Sterilization
• High temperatures may damage more heat-sensitive items such as rubber or
plastic goods.
• Sterilization cycles are prolonged at lower temperatures. Heavy loads of
instruments, crowding of packs, and heavy wrapping easily prevent
sterilization.
• Cycles are not automatically timed on some models. Inaccurate calibration,
lack of attention to proper settings, and adding instruments without
restarting the timing are other common sources of error.
ETHYLENE
OXIDE(ETOX)STERILIZATION
• ETOX sterilization is the best method for sterilizing complex
instruments and delicate materials.
• Automatic devices sterilize items in several hours and operate at
elevated temperatures well below 100°C. Less expensive devices
operate overnight to produce sterilization at room temperature
• Porous and plastic materials absorb gas and require aeration for 24
hours or more before it is safe for them to contact skin or tissues.
• Units with large chamber sizes hold more instruments or packs per
cycle; however, they are expensive. Some chamber designs or sizes
are better suited to accept stacks of instrument trays
ethylene oxide
sterilizer
Boiling Water

• Boiling instruments in water does not kill spores and cannot sterilize
instruments.
• Heat can reach and kill blood-borne pathogens, however, in places that
liquid sterilants and disinfectants used at room temperature cannot reach.
• Boiling is a method of high-level disinfection that has been used when
actual sterilization cannot be achieved (e.g., in case of a sterilizer
breakdown).
• Well-cleaned items must be completely submerged and allowed to boil at
98°C to 100°C (at sea level) for 10 minutes. Great care must be exercised to
ensure that instruments remain covered with boiling water the entire time.
• Simple steaming is unreliable. Pressure cooking, similar to steam
autoclaving, is preferable and would be required at high altitudes
Monitors of sterilization
• Effective instrument is ensured by routine monitoring of instrument
sterilization,which has become a standard of care
• Sterilization monitoring has five components
1. Mechanical monitoring
2. Chemical indicator strips
3. External sterilization indicators
4. Biologic monitoring strips
5. Documentation log
1. Mechanical Monitoring
• Each sterilized load must be mechanically monitored to document time,
temperature, and pressure. Many sterilizers have a printout tape that does
this automatically. Otherwise, the clinician manually observes the maximum
temperature and pressure and documents the data in a log.
2. Chemical Indicator Strips
• Chemical indicator strips provide an inexpensive, qualitative monitor of
sterilizer function, operation, and heat penetration into packs.
• The clinician places one of the inexpensive color- change indicator strips
into every pack. Chemicals on the strip change color slowly, relative to the
temperature reached in the pack.
• As soon as the pack is opened, the strip can immediately identify
breakdowns and gross overloading. The strip is, however, not an accurate
measure of sterilization time and temperature exposure
chemical process indicator demonstrating the colour
change which occurs when they have been through a
sterilization cycle
3. External Sterilization Indicators
• External sterilization indicators, including tapes and bags, are marked with
heat-sensitive dyes that change color easily on exposure to heat, pressure,
or sterilization chemicals.
• Such heat-sensitive markers are important to identify and distinguish the
packs that have been in the sterilizer from those that have not. Used alone,
these indicators are not an adequate measure of sterilization conditions.
• Sterilization is task dependent as much as time and temperature
dependent. Packs should always be dated and rotated
4. Biologic Monitoring Strips
• A biologic monitoring spore test strip is the accepted weekly monitor of
adequate time and temperature exposure.
• Spores dried on absorbent paper strips are calibrated to be killed when
sterilization conditions are reached and maintained for the time necessary
to kill all pathogenic microorganisms.
• Additionally, any pack containing an implantable device must be
biologically monitored. An assistant processes a spore strip in a pack of
instruments in an office sterilizer each week.
• Tests can be evaluated in the office. By sending the strip to a licensed
reference laboratory for testing, however, the dentist obtains independent
documentation of monitoring frequency and sterilization effectiveness.
5. Documentation log
• In a log,a single,dated,intialed indicator strip is attached to sheet or calendar
for each workday,followed by a weekly spore strip report
• The log provides valuable sterilization documentation
Liquid Sterilants and High-Level Disinfectants
• Liquid sterilants can kill bacterial spores in 6 to 10 hours. These sterilants are
high-level disinfectants and are EPA registered.
• Sterilants used for high-level disinfection of items for reuse are
glutaraldehydes at 2% to 3% concentrations. Repeated use greater dilutions
are not advisable.
• Organic matter and oxidation reduce the activity of reused disinfectant
baths. Placing wet items into disinfectant trays dilutes the solution.
• Despite reuse claims of several weeks’ duration, studies have shown that
disinfectants in heavy use often lost activity during the second week
• Glutaraldehydes are irritating, are sensitizing to skin and respiratory
passages, and can be toxic as indicated in manufacturers’ safety data
sheets.
• Trays should be kept tightly covered in a well-vented area. Use of 2% or
greater glutaraldehyde solutions to wipe counters or equipment (e.g.,
dental unit and chair) should be avoided.
• Most glutaraldehydes require 20 minutes to kill tuberculosis bacteria, in
contrast to some synthetic phenol complexes and alcohols, which act in 10
minutes or less and are much less toxic
Sterilization of Handpieces and Related Rotary
Equipments
Steam Sterilization of Handpieces
• Autoclave sterilization of handpieces is one of the most rapid
methods of sterilization. If proper cleaning and lubricating are
performed as prescribed by the manufacturer, the usefulness
of the instruments can be maintained with regular autoclaving.
• Fiber optics tend to dim with repeated heat sterilization in
several months to a year, apparently owing to oil residue and
debris baked onto the ends of the optical fibers.
• Cleaning with detergent solution and wiping ends of optics
with alcohol or other suitable organic solvents may prolong use
before factory servicing. Manufacturers continue to improve
the methods of preparing handpieces for sterilization
Clean handpiece by wiping it
with a suitable disinfectant Lubricate handpiece before
sterilization
Other Methods of Handpiece Sterilization
• Chemical vapor pressure sterilization recommended for some types of
handpieces apparently works well with ceramic- bearing handpieces
• ETOX gas is the gentlest method of sterilization used for handpieces.
Internal and external cleaning is important. Otherwise, preparation of
handpieces before sterilization is not as critical because no heat is involved.
Oil left in handpieces, however, can impair sterilization.
• Dry heat sterilization of handpieces is generally not recommended
Refernces
• Sturdevant’s Art and Science of Operative dentistry - 6th Edition
• Nisha Garg Textbook of Operative Dentistry - 3rd Edition
• Peng, X., Xu, X., Li, Y. et al. Transmission routes of 2019-nCoV and controls in dental
practice. Int J Oral Sci 12, 9 (2020). [Link]
• Wu, Yi-Chia; Chen, Ching-Sunga; Chan, Yu-Jiuna,b,c,*. The outbreak of COVID-19: An
overview. Journal of the Chinese Medical Association 83(3):p 217-220, March 2020. |
DOI: 10.1097/JCMA.0000000000000270
• Basic guide to InfectIon PreventIon and Control In Dentistry-Second Edition Dr
Caroline L. Pankhurst (King’s College London Dental Institute )Professor Wilson A.
Coulter(University of Ulster)
• Miller, Chris H. (Microbiologist),Infection control and management of hazardous
materials for the dental team / Chris H. Miller. Description: Sixth edition. ISt. Louis,
Missouri: Elsevier, [2018] Includes bibliographical references and [Link]
2016048959 (print) LCCN 2016050617 (ebook) lSBN 9780323400619 (paperback.:
[Link]) ISBN 9780323484282 (E-book)
• Infection control in dental office Louis G. DePaola, Leslie E. Grant ISBN 978-
3-030-30084-5 ISBN 978-3-030-30085-2 (eBook)
[Link]
• Int J Environ Res Public Health. 2022 Mar; 19(5): 2537. Published online
2022 Feb 22. doi: 10.3390/ijerph1905253
THANK YOU