SEMINAR

STERILIZATION IN OPERATIVE DENTISTRY

PREPARED BY DR.KAMARAN HUSSEIN HASSAN HIGH DEGREE DIPLOMA STUDENT CONSERVATIVE DEPARTMENT 2013

Sterilization in operative dentistry

Sterilization: is the total elimination or destruction of all microorganisms including (bacteria,viruses,spores and fungi). Disinfection: is the process of elimination of most pathogenic microorganisms (excluding bacterial spores) on inanimate objects. Cleaning: is the removal of all foreign materials (dirt and organic matter) from instruments and equipments. We have two ways of cleaning either manual or mechanical. The manual cleaning is done by water and detergents while the mechanical cleaning includes ultrasonic cleaners or washers (disinfectors) that may facilitate cleaning documentation of some items and may reduce the need for manual cleaning. Methods of sterilization We have four accepted method of sterilization 1.steam pressure sterilization (autoclave). 2.chemical vapor pressure sterilization (chemiclave). 3.dry heat sterilization (dryclave). 4.ethylene oxide sterilization. Each method of sterilization has very specific requirements regarding timing,temperature,suitable packaging of materials,and kinds of items and materials that can be safely and effectively sterilized. 1.Steam pressure sterilization (Autoclaving). Sterilization with steam under pressure is performed in a steam autoclave .for a light load of instruments ,the time required at (121c) is a minimum of 15 minutes at 15 pounds of pressure .time for wrapped instruments can be reduced to 7 minutes if the temperature is raised to approximately (134c) to give 30 pounds of pressure .time required for the sterilizer to reach the correct temperature is not included .bench models may be automatic or manually operated .manual

sterilizers should have both a temperature and pressure gauge so temperatures can be related to corresponding temperatures required for sterilization . Advantages of Autoclaves Autoclaving is the most rapid and effective method for sterilizing cloth surgical packs and towel packs .Burs can also be sterilized by keeping them submerged in a small amount of 2% sodium nitrite solution. Disadvantages of Autoclaves Items sensitive to the elevated temperature cannot be autoclaves. autoclaving tends to rust carbon steel instruments and burs. Steam appears to corrode the steel neck and shank portions of some diamond instruments and carbide burs. 2.Chemical vapor pressure sterilization(chemiclaving) Sterilization by chemical vapor under pressure is performed in a chemiclave .chemical vapor pressure sterilizers operate at 131c and 20 pounds of pressure.They are similar to steam sterilizers and have a cycle time of approximately half an hour.like ethylene oxide sterilizers they must be used with a prescribed chemical and should be properly labeled to satisfy OSHAs chemical hazard communication standard. Advantages of chemiclaves Carbon steel and other corrosion-sensitive burs,instruments,and pliers are said to be sterilized without rust or corrosion. Disadvantages of chemiclaves Items sensitive to the elevated temperature will be damaged .instruments must be lightly packaged in bags obtained from sterilizer manufacturer.towels and heavy cloth wrappings of surgical instruments may not be penetrated to provide sterilization. 3.Dry heat sterilization A.Conventional dry heat ovens Dry heat sterilization is readly achieved at temperatures above 160 c .conventonal professional dry heat ovens that have been sold for instrument sterilization have heated chambers that allow air to circulate by gravity flow.packs of instruments must be placed at least 1 cm apart to allow heated air to circulate.individual instruments must actually be heated at 160 c for 30 minutes

to achieve sterilization.Increasing the total time by 50% as a safety factor is recommented.total time required also depends on the efficiency of the Oven for its size ,the size of the load ,and how instruments are packaged.foil wrap or special nylon bags are used. B.Short-cycle,high-temperature dry heat ovens. A rapid high temperature process that uses a forced draft oven(a mechanical convection oven that circulates air with a fan or blower) is available .it reduces total sterilization time to 6 minutes for unwrapped and 12 minutes for wrapped instruments.these short-cycle high-temperature dry heat ovens operate at approximately 185 c to190 c . 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. Disadvantages of dry heat sterilization High temperatures may damage more heat-sensitive items .such as rubber or plastic goods.sterilization cycles are prolonged at the lower temperature.heavy loads of instruments,crowding of packs,and heavy wrapping easily defeat sterilization. 4.Ethylene oxide sterilization Ethylene oxide sterilization is the best method for sterilizing complex instruments and delicate materials.porous and plastic materials absorbe the gas and require aeration for 24 hours or more before it is safe for them to contact skin or tissues. New methods of sterilization A.Microwave oven The microwave oven has major limitations for sterilizing metal items ,by either damaging the machine or not reaching all sides of instruments. B.Ultraviolet irradiation Ultraviolet light is not highly effective against RNA viruses such as HIV and is not very effective against bacterial spors.incomplete exposures of all surfaces and poor penetration of oil and debris are other limitations.ultraviolet irradiation may be useful for sanitizing room air to help control tuberculosis bacteria. C.Glass bead sterilization

Glass bead sterilizers use small glass beads and high temperature for brief exposure times to inactivate microorganisms.Glass bead sterilizers are difficult to monitor for effectiveness, have inconsistent heating resulting in cold spots, and often have trapped air which affects the sterilization process. Glass bead sterilization is not an acceptable method of sterilization for medical equipment/devices. Other methods for Disinfection A.Boiling The use of boiling water to clean instruments and utensils is not an effective means of sterilization. Boiling water is inadequate for the destruction of bacterial spores and some viruses. In the home care environment, boiling may be used for high-level disinfection for equipment/devices re-used on the same client, following adequate cleaning. B.Flash sterilization Flash sterilization shall only be used in emergency situations and shall not be used for implantable equipment/devices,or on complete sets or trays of instruments.Sterilization is a process, not an event. Operative scheduling and lack of instrumentation do not qualify as reasons to use flash sterilization. C.Liquid sterilization Liquid sterilants are those that 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.greater dilutions are not encouraged for repeated use. Why Is Infection Control Important in Dentistry? Both patients and dental health care personnel (DHCP) can be exposed to pathogens Contact with blood, oral and respiratory secretions, and contaminated equipment occurs Proper procedures can prevent transmission of infections among patients and DHCP Modes of Transmission

 Direct contact with blood or body fluids Indirect contact with a contaminated instrument or surface Contact of mucosa of the eyes, nose, or mouth with droplets or spatter Inhalation of airborne microorganisms How are diseases transmitted in the dental setting? From the patient to the dental worker From the dental worker to the patient From one patient to another patient Dentist-patient protection Handwashing. The use of personal protective equipment, such as gloves, masks, eye protection, and gowns, that are intended to prevent the exposure of skin and mucous membranes to blood and other potentially infectious materials. Proper cleaning and decontamination of patient care equipment. Cleaning and disinfection of environmental surfaces. Injury prevention through engineering controls or safer work practices. Use single use disposable items and equipments.

STERILIZATION OF HANDPIECES AND RELATED ROTARY EQUIPMENT Prophy angles, latch angles burs, and rotary stones used in the mouth must be cleaned and sterilized for reuse.All such items are readily sterilized by three or more methods of sterilization. Carbon steel burs require special protection in the autoclave . Handpieces are semicritical instrumentation requiring sterilization. Few brands now exist on the market that cannot be routinely autoclaved. Sterilization of handpieces must be monitored and documented.The motor end of the attached low-speed handpiece canbe covered by pulling a disposable, single use, slender plastic bag up over it and pushing (popping) the hand-piece through the sealed end of the bag so the bag covers the motor end and part of the hose Otherwise scrub and disinfect the motor-end for eachreuse if it cannot be sterilized. STEAM STERILIZATION OF HANDPIECES

Autoclave sterilization of handpieces is one of the most rapid methods. If proper cleaning and lubricating is per-formed as prescribed by the manufacturer, good utility is obtainable with regular autoclaving. Fiber optics dim with repeated heat sterilization in a number of months to a year, apparently due to oil residue and debris baked on the ends of the optical fibers. Cleaning with detergent so-lution and wiping ends of optics with alcohol or other suitable organic solvents may prolong use before factory servicing. Manufacturers are improving methods of preparing handpieces for sterilization. Consult the man-ufacturer's for current advice and warnings. I NFECTION CONTROL FOR IMPRESSIONS AND RELATED REGISTRATIONS FACTORS IN MAKING IMPRESSIONS AND ASSOCIATED REGISTRATIONS THAT WILL BE SENT TO A REMOTE LABORATORY Precautions are required for IC in making impressions and associated bite registrations, just as for other operative procedures.Universally apply barrier protection for personnel against contamination from mucosa, saliva, and blood by use of adequate PPE, such as gloves, mask,and appropriate overgarment .To eliminate any chance of cross-contamination when sizing impression trays, place the tray in a plastic baggy before it is tried in the mouth. After the appropriate size has been determined, remove the baggy and proceed with impression making. Indicate the tray size on the patient's chart to eliminate further try-ins. For IC, custom resin trays for impressions made with nonaqueous rubber impression materials are used once and then discarded. Likewise, stock trays are used only once and discarded.Before making the impression and associated bite reg-istrations, use clean, gloved hands to dispense as many materials and disposable items as possible. This avoids contaminating their containers. Whenever possible, use unit dose packaged materials, or use a paper towel or plastic film to handle tubes and other reused containers. Least satisfactory, but adequate, is wiping material con-tainers with a disinfectant after the procedures. A satis-factory disinfectant should be an EPA-approved tuber-culocidal disinfectant. PERSONAL BARRIER PROTECTION Gloves. OSHA regulations specify that all clinical personnel must wear treatment gloves during all treatment procedures. After each appointment, or if a leak is detected, remove gloves, wash hands, and put on fresh gloves. Gloves must not be washed or used for more than one patient. Inexpensive disposable well-fitting treatment gloves are available for chair-side use. They should be dispensed carefully to avoid contaminating others in the box. The value of gloves was

emphasized by finding that without gloves,occult blood persisted under dentists' fingernails for several days after patient contact. Gloves also help prevent very painful and transmissible herpetic infections to fingers (Whitlow) and hands. Protective Eyewear, Masks, and Hair Protection . Protective eyewear may consist of goggles, or glasses with solid side-shields. Wear a mask to protect against aerosols. Face shields are appropriate for heavy spatter, but a mask is still required to protect against aerosols that drift behind the shield. Spatter also can pass under the edge of a short shield and strike the mouth. Anti-fog solution for eyewear can be obtained from opticians or product distributors. Masks with the highest filtration are rectangular, folded types used for surgeries. 40 Dome-shaped masks are adequate barriers against spatter and are considered to prevent HB and HIV infection. They are not adequate to hold back measles, influenza, and other aerosol-borne respiratory viruses or tuberculosis bacteria. To best protect against aerosols, press edges of the rectangular mask close around the bridge of the nose and face. Personnel must protect their hair with a surgical cap when encountering heavy spatter (e.g., from an ultrasonic scaling device).

I NHERENT WATER SYSTEM CONTAMINATION

Microbes exist in the dental unit waterline as free floating bacteria and as a sessile form known as biofilm.The microorganisms in the biofilm produce a protective polysaccharide matrix that provides them a mechanism for surface attachment and retention to the waterline .This matrix, which can be 30 to 50 um thick, affords the biofilm flora resistance to antimicrobial agents on the order of 1500 times greater than normal free-floating bacteria. Because of this resistance to antimicrobial agents, once the biofilm is established, it is very difficult to remove. Bacterial growth in biofilms on the inner walls of dental unit water lines is a universal occurrence unless steps are taken to control it." Counts of bacteria that are shed from the biofilms into water of the dental unit may range from thousands to hundreds of thousands of bacteria per milliliter. This bioload could be compared with bacterial counts of some foods (e.g., juices, milk, yogurt) except that the bacterial types present are not carefully controlled. The main inhabitants are opportunistic,gram-negative, aquaphilic bacteria. Similar species are found in biofilms that form in swimming pools or wherever nonsterile water remains in prolonged contact with habitable surfaces. The bacteria may include atypical Mycobacteria, Pseudomonas, and possibly Legionella bacteria, which can present an infection risk to immunocompromised persons. Flushing or sterilizing high-speed handpieces cannot be expected to overcome this potential source of contamination of patients and personnel that extends throughout the dental unit water system.The public health threat of biofilm in dental unit waterlines has not been established. However, as the characteristics of the population changes, the link between biofilm bacteria and infection may be verified. The ADA recommended that IC measures be established and followed such that dental unit treatments would contain less than 200 colony-forming units (cfu) per milliliter of bacteria by the year 2000. Suggested mechanisms to accomplish this goal of 200 cfu/ml include use of microbial point-of-use filters and independent water systems. The uses of biocide solutions to treat the waterlines solization of mycobacteria that cause pulmonary tuberculosis (Mycobacterium tuberculosis) has always been a concern, although an infectious patient coughing in the waiting room or operatory is clearly much more likely to infect others. Annual tuberculin testing of personnel has been a standard IC recommendation in dentistry. There is also concern about nosocomial airborne transmission of multidrug-resistant strains of mycobacteria that have exhibited an 85% infection rate and have been lethal for 75% of infected immunocompromised persons in 16 weeks . This poses a concern for health of dental personnel as well.The rubber dam and high-volume evacuation (HVE) are very important and helpful methods for reducing exposure to contamination . FIVE can be up to 80% effective in reducing aerosol contamination. However, there is no way to completely eliminate airborne contamination,unless some method of continuous air purification can be used. Without the universal use of personal barriers, drapes, and/or effective cleanup procedures, personnel, and subsequent patients can be subjected to oral fluid-borne contamination.

Dental instruments are classified into three categories depending on the risk of transmitting infection. The classifications of critical, semi-critical and non-critical are based on the following criteria:

Critical Instruments
Are those used to penetrate soft tissue or bone, or enter into or contact bloodstream or other normally sterile tissue. They should be sterilized after each use. Sterilization is achieved by steam under pressure (autoclaving), dry heat, or heat/chemical vapor. Critical instruments include forceps, scalpels, bone chisels, scalers and surgical burs.

Semi-critical Instruments
Are those that do not penetrate soft tissues or bone but contact mucous membranes or non-intact skin, such as mirrors, reusable impression trays and amalgam condensers. These devices also should be sterilized after each use. In some cases, however, sterilization is not feasible and, therefore, high-level disinfection is appropriate. A high-level disinfectant is registered with the U.S. Environmental Protection Agency (EPA) as a "sterilant/disinfectant" and must be labeled as such.

Non-critical Instruments
Are those that come into contact only with intact skin such as external components of x-ray heads, blood pressure cuffs and pulse oximeters. Such devices have a relatively low risk of transmitting infection; and, therefore, may be reprocessed between patients by intermediate-level or lowlevel disinfection. An intermediate-level disinfectant is EPAregistered as a "hospital disinfectant" and will be labeled for "tuberculocidal" activity (e.g., phenolics, iodophors, and chlorinecontaining compounds). A low-level disinfectant is EPA- registered as a "hospital disinfectant" but is not labeled for "tuberculocidal" activity (e.g., quaternary ammonium compounds). The tuberculocidal claim is used as a benchmark to measure germicidal potency. Germicides labeled as "hospital disinfectant" without a tuberculocidal claim pass potency tests for activity against three representative microorganisms: Pseudomonas aeruginosa, Staphylococcus aureus, and Salmonella choleraesuis