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STERILIZATION OF ARMAMENTARIUM

5.5 billion/mL of saliva

Avg 750 million/mL of saliva

Thousands of species of bacteria, fungi and viruses.

Myriad oral niches-tongue, gingival, teeth etc

Doctors, dentists, patients, diseases

Herpes, T.B., Hepatitis, AIDS.

AFRAID?

We better be-

Let us explore this world of heat, light, chemical, gases etc. under the
following subheadings:

 INTRODUCTION

 DEFINITIONS

 HISTORY

 PRELIMINARIES

 STERILIZATION

 DISINFECTION

 SPECIFIC CONSIDERATIONS INCLUDING HANDPIECES,


DENTAL BIOFILMS AND DENTAL ARMAMENTARIUM AND
SPECIFIC DISEASE

 CONCLUSION

 BIBLIOGRAPHY

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INTRODUCTION:

Today is the age of modern technology and wizardly gedgation. Today is

also the age of medical challenges. From the “back with a vengeance”

tuberculosis, to the ever prevalent tetanus, typhoid, measles to the modern

day pandemics of hepatitis and AIDS, the challenge of microbial infections

is omnipresent and ever threatening. Into this scenario comes the dental

professional being the center of a health care delivery system, dentists are

not only at risk themselves but also pose a pathway of infection to their

numerous patients. Thus it becomes the religion of every dentist to

implement all those practices and procedures that will result in minimizing

the microbial challenge. Let us see how.

Firstly the definitions:

STERILIZATION: It is defined as freeing the object or substance from all

life of any kind.

It is defined alternatively as the process by which an article, surface or

medium is freed of all microorganisms either in the vegetative or spore

state.

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DISINFECTION: It means the killing, removal of or destruction of

organisms capable of causing infection namely pathogens.

Disinfectant: Is an agent accomplishing disinfection. It is applicable to

inanimate objects.

Antiseptic: Closely linked to disinfection, it inhibits or destroys pathogens

and is applicable to living tissues.

Germicide means killing of germs.

Bactericide means killing of bacteria while bacteriostatic mean reversible

inhibition of bacteria growth without killing them.

Sanitizers are agents, including detergents, used to maintain microbial

levels at safe, acceptable levels.

Asepsis is the absence of infections microorganisms in bony tissues i.e.

absence of sepsis. It is a term applied to any techniques designed to keep

all unwanted microorganisms out of any field of work or observation and

involves a gamut of aspectic techniques. Gnoto biotics is asepsis at its

zenith.

Cross infection or cross contamination is the passage of microorganisms

from one person to another via any route, direct or indirect.

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Microbiostasis agents are substances or conditions that do not immediately

kill microorganisms but inhibit them, so that after an initial decline,

microbes die without significant multiplication.

HISTORY:

Zaccharis Jannsen, in 1590 and Robert Hooks in 1660 opened the world of

microbes to mankind by their inventions of monocarps. It was Anthony

Van Leuwenhock who first described microorganisms (1667).

It was Joseph Lister, between 1865-1891 who delineated the principles of

wound infection and asepsis.

Further process effort of Louis Pasteur added new direction to the field of

sterilization.

Input by various researchers like John Lyndall, Robert Koch etc. further

accelerated the progress, when finally in the 1890’s the advent of stear

sterilization, surgical modes, sterile gloves, gowns, drapes and sterile

sponges engaged.

The modern infection control recommendation and sterilization guidelines

were stated by the CDC in 1973 and specific dental infection control

guidelines and the ADA is 1878 revised in 1985, and 1988 also defined in

1986 by CDCC with OSHA (occupational safety and health

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administration). Comprehensive guidelines for infection control come into

effect in Dec. 1991 and continually being ungraded to incorporate the mind

numbering advancements in the field.

Rationale for sterilization: The basic question among is why should we

sterilize:

The basic answer lies in the fact that we sterilize to minimize and eliminate

the spread of infection and disease. In his classic demonstration in the

1970’s Crawford demonstrated the magnitude of the problem of cross

contamination by supporting saliva as a red dye and demonstrating

alarming results.

Infections microbial agents can spread by direct contact, indirect contact

via a contaminated surface or material, spattering of secretions and

aerolization.

A look here at the small list of microorganisms demonstrates how

Herculean the task is and what risk dentists themselves face-as do their

patients and auxillaries.

Doesn’t look all that small does if. Also mention AIDS, hepatitis, TB, viral,

bacterial etc.

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Thus infection control involves:

1. Reduction of pathogen concentration to allow normal host

resistance mechanisms to prevent infection.

2. Break the cycle of infection and eliminate cross-infection.

3. treat every patient and instrument as potentially infections and

therefore employ universal safety precautions and

4. protect patient and personnel from occupational infection.

Utilization of proper sterilization, disinfectants and aseptic procedures

helps to achieve the safety or profession demands.

The preliminaries:

So, beginning the holistic plan of infection control of which sterilization is

a key ingredient, firstly comes the patient HEALTH EVALUATION:

The beginning is made by performing the patient health evaluation. This is

essentially a thorough and exhaustive medical examination and history

evaluation, so as to be forewarned and forearmed towards any infectious

risks. It helps in:

1. Detecting any unrecognized illness requires medical diagnosis and

care.

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2. identifying infection or high risk that may be important to a clinical

personnel exposed during examination, treatment or cleanup.

3. Assisting in managing and caring for infected patients.

4. reinforcing use of adequate infection control universal procedures

bearing in mind that general history taking is not capable of

detecting all infections.

A complete examination of all organ systems and checklist of possible

infections risks coupled with a knowledge of previous diseases all correlate

towards a more effective sterilization regimen. Sir William Osler’s

statement “Never treat a stranger” finds strong reinforcement in the field of

aseptic dentistry.

Personal protective equipment and barrier technique:

These encompasses all those materials, protectives and techniques that

comprise and aid in an aseptic technique.

Personal barrier protection

OSHA (Occupational health and safely administration) have


suggested basic areas for personal barrier protection. They are :

1. Hand washing.
2. Gloves

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3. Gowns
4. Masks
5. Protective eye wear
6. Rubber dam
7. Pre procedural mouth rinse.

Hand washing : Hands must always be washed at the start of each day
before gloving, after removal of gloves and after touching inanimate
objects likely to be contaminated by patients saliva or blood . Hand
washing with plain soap and water appears to be adequate for routine
examination and non surgical procedures. For surgical procedures an
antimicrobial surgical hand scrub should be used. Hand washing procedure
begins with a thorough initial scrubbing of all surfaces of the nails, fingers,
hands and lower arms with an antimicrobial preparation. Drying should be
done with a clean paper towel.

All gross subnail contaminations should be removed. The scrub


begins at the tip of one finger of one hand. The long axis of the finger is
then divided into 4 surfaces and 30 scrub strokes are applied to each
surface. After this the inter finger webbing is given 30 strokes. The length
of the forearm is divided onto thirds and each of the four surfaces is
scrubbed toward the elbow. After both arms are scrubbed the rinse should
be done with elevated arms so that the H2O will drain from the fingertips
down the hands, arms and finally the elbows.

Gloves : Gloves are required in dentistry when the dentist has to come in
contact with potentially infectious secretions or for contact with oral
mucous membrane. Four types of gloves are identified for use in dentistry.

i. Sterile surgical gloves.


ii. Non sterile latex gloves.

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iii. Vinyl examination gloves.
iv. Utility gloves.

Surgical gloves : Best fitting and generally the most expensive disposable
gloves is the sterile surgical glove. Used when maximum protection is
indicated. They are made of high quality latex.

Latex examination gloves : These are the most commonly used gloves in
dentistry. Available in a variety of sizes designated as S,M,L.

An occassional hyper sensitivity to latex has been reported.


Inadequately drying the hands before gloving has proven to cause
dermatitis.

Vinyl examination gloves :Sometimes referred to as “Over gloves”. Used


when an intra oral procedure is necessarily interrupted for a brief time.
Following a washing and drying of the gloved hands, the over gloves can
be slipped on over the regular examination gloves and removed when
contact with the patient resumes.

Heavy utility gloves : These are non disposable gloves. They should be
worn when handling contaminated instruments, when using chemical
sterilants and during general cleaning of the treatment area. These gloves
can be washed, sterilized, disinfected and reused and are puncture resistant.

Protective clothing gowns

Gowns, Aprons or lab coats must be worn when the skin or clothing
is likely to come in contact with saliva or blood. They should be changed
when visibly soiled. These garments should be limited to the dental office
and not be worn out side.

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Masks :

Masks protect the face, oral mucosa and nasal mucosa of the dentist
from splatter of blood or saliva from the use of high speed hand piece with
water coolant.

It also protects both the dentist and the patients from aerosol
contamination by potential from the respiratory tract.

Effective face masks are to have a minimum filtration of 95% of


3.5m particles and the ability to block aerosols as well as larger particles
of blood, saliva and oral debris. A good mask should have the following
features.

- Fit comfortably.
- Not leak out air
- Fit around the entire periphery of the face.
- Not irritate skin.
- Provide breathability.
- Not cause fogging of protective eyewear.
- Not have an objectionable odour.
- Not touch lips or nostrils.

Face masks should be changed once per hour or between each


patient. The mask should not be touched because wet masks significantly
decrease the filtration capacity.

They are available in a variety of materials like paper, cloth, foam,


fibre glass and other synthetic materials.

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Protective eye wear

All dental personnel involved in treatment should wear protective


eye wear in the form of glasses to prevent trauma to the eye tissue from
flying droplets or aerosols.

The eyes due to limited vascularity and lower immense abilities are
susceptible to macroscopic and microscopic injury.

Protective eye wear should be available to patients as well as dental


personnel. The supine position renders the patient particularly vulnerable to
falling objects in the head and neck area. Ultrasonics and high speed hand
piece spray create potential pathogenic aerosols, droplets and spatters
pieces of enamel, amalgam, gold and pumice can be flung and propelled
from the oral cavity.

All protective eyewear should be cleansed after every appointment.


Eyewear be washed with soap first, then rinsed with water and an
appropriate surface disinfectant can then be used.

Rubber dam :

The use of a rubber dam during certain dental procedures is


advocated. The role of the dam in barrier technique is emerging as yet
another means of controlling airborne contaminants.

Rubber dam isolation has been shown to significantly reduce


infectious particles in aerosols. Used in combination with a pre-operative
rinse of chlorhexidine gluconate the risk of contamination can be further
reduced.

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Pre procedural mouth rinse

The use of antimicrobial mouth rinse prior to any operative


procedure reduces the microorganisms that may escape a patients mouth
during dental care through aerosols, spatters or direct contact.

Examples of antiseptic mouth rinses are :

a. Chlorhexidine, Alexidine from Bis-geranide class.


b. Octenidine of Bis-pyridine class.
c. Iodine, iodophors from halogen group.
d. Peroxide, perborate of oxygenating agents.
e. Phenol, Thymol from phenolic compounds.
f. Hexitidine from pyrimidines.
g. Benzethonium chloride from quaternary ammonium group.

Although the antiseptic mouth rinses are effective in reducing the


oral micro-organisms, they are bitter in taste and cause staining of teeth.

Infection control consideration in the field of restorative dentistry


and Endodontics

The primary goal of infection control is to reduce the risk of cross


contamination between patients and the dental professionals. The same
general principles of infection control are applicable in the field of
restorative dentistry and endodontics are discussed.

The most accepted methods of sterilization can be classified as


follows:

A) Mechanical or physical; B) Chemical

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A) Mechanical is further classified into:

1) Sunlight; 2) Drying, 3) Dry heat – this includes flaming, incarnation

and hot air; 4) Moist heat includes pasteurization, boiling, steam

under normal and high pressure, chemical vapors under pressure,

tyndallization, 5) filtration including candles, asbestos pads,

membranes; 6) Radiation’ 7) ultrasonic and sonic vibrations.

B) Chemicals used in sterilization include alcohols, aldehydes, dyes,

halogens, phenols, surface-active agents, metallic salts, and gases though

many authors state that:

Ethylene oxide is the only chemical considered as a sterilant while others

are more often described as disinfectants.

Under mechanical:

1. So first is sunlight – It possesses appreciable bactericidal activity

and is responsible for spontaneous sterilization under natural

conditions. It has limited clinical utility.

2. Drying : Moisture is essential for bacteria, drying therefore has a

deleterious effect on most bacteria. Spontaneous drying can often

kill bacteria while viruses are more resistant. However, the method

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is highly unreliable, spores are unaffected by drying and can remain

viable for long periods.

3. Next we come to heat: This is the most popular, widely used and

reliable source of sterilization which is the technique of universal

choice until contraindicated:

Heat is the method recommended by OSHA, CDC and ADA it can be

utilized in 2 form – moist and dry heat.

A) Dry heat means the use of heat without any moisture content. It

involves various forms namely:

1) Flaming: Innoculating loops or wires, points of forceps and searing

spatulas are held in a Bunsen flame till they become red hot for

sterilization.

Scalpel, needles, mouth of culture tubes, glass slides, cover stips etc

could be flame sterilized.

2) Incineration: This is an excellent method for rapidly destroying

materials such as sealed dressings, animal corcases, bedding and

pathological materials. Plastic like PVC and polythene can also be

incinerated. Incinerated material should be carefully disposed off.

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3) Conventional dry heat hot air ovens: This is the more commonly

used form of dry heat. Dry heat kills by proteins denaturation,

oxidative damage and the toxic effect of elevated levels of

electrolytes. Dry heat sterilization is readily achieved at temperature

above 320°F (160°C). Conventional hot air ovens have heated

chambers that allow air to circulate by gravity flow i.e. gravity

connection. Packs of instrument must be placed at least 1cm apart

and a 2 hour holding period at 160°C or/ how at 170°C is used with

variations existing. A higher load increases the time factor. Glass

were, forceps, scissors, swabs, pharmaceutical products can all be

sterilized. The oven is usually heated by electricity with a blower to

ensure even air distribution. Oil, glycerol, greases can be sterilized

at 150°C for 1 hour while among rubbers only silicon rubbers can

withstand high heat.

Another innovation are the short cycle, high temperature dry heat ovens.

A rapid high temperature process that was a forced draft oven (a

mechanical connection oven with a fan or blow for air circulation) reduces

sterilization time to 6 minutes for unwrapped and 12 minutes for wrapped

instruments. These short cycle oven operate at 370-375°F (190°C). any

type used must be properly calibrated and approved. The main precaution

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is that the sterilization is done after the temperature reaches the required

setting.

The advantages includes effective and safe sterilization of metal

instruments and errors with no corrosion of carbon steel instruments and

burs. Rapid cycles can be used at high temperatures and cutting edges are

not dulled through disrupted by Cuate and Loyle.

Disadvantages include long cycles, poor penetration, damage to heat

sensitive items. Heat labile items cant be sterilized by this method.

Leverage for error is more due to sensitivity to load cycles, inaccurate

calibration, heavy wrapping etc.

Dry heat efficiency can be verified by proper strips impregnated with 10 6

nontoxigenic Clostridia tetani spores or Browne’s tube green spot test. Also

external temperature gauges i.e. pyrometers and thermocouples can be

used.

4) Next technology utilizing high heat are those operating on heat

transfer devices.

These are of special interest to the endodontist and general dental

practitioner as they encompass the glass bead and salt media sterilizers.

Glass beads, molten metal and salt are media often used. It essentially

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consist of a metal cup in which table salt or glass beads are kept at a

temperature between 425°F(218°C) and 475°F(246°C). A thermometer is

used with the unit of temperature indication devices are not incorporated.

At this temperature root canal instruments such as broaches, files and

reamers may be sterilized in 55 and absorbent points and cotton pellets in

105. It does not affect the temperature of instruments in any way. The hot

salt sterilizer has superseded the molten metal and glass bead sterilizer

because metal or glass beads could accidentally cling to the instrument and

get lodged in root canals, clogging them. Salt eliminates this risk and usual

commercial table salt containing about 1% of sodium silica aluminate,

magnesium carbonate or sodium carbonate to improve flow and decrease

fusion is used. Salt should be changed weekly. Glass beads are often used

and their size should be less than 1cm. The hottest part of this apparatus is

along the outer rim at the bottom most layer and lowest in the center of the

surface layer. Hence a minimum of ¼ inch insertion below the surface in

the peripheral area is recommended by Oliet, Sonin, Engel hardt, Walter

etc. a warm up time of 20 minutes ensures on firm temperature ranges. This

device is indispensable in endodontic armamentarium sterilization.

Going further, we now come to the most widely used form of heat

sterilization – moist heat:

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The lethal effect is due to denaturation and coagulation of protein and its

latent heat liberation.

The various modalities are:

1) Temperature below 100°C.

a) Pasteurization: Pasteurization of milk is done at 63°C for 30 minutes

(hold method) or 72°C for 15-20s (flash process) followed by

cooling to 13°C or laser vaccines are heat inactivated in special

vaccine bath at 60°C for 1 hour. Serum or body fluids can be

sterilized at 56°C for 1 hour for several successive days. Media such

as LJ and Loeffler’s can be sterilized 80-85°C for ½ hour on 3

successive days is an inspirator. Many other sensitive instruments

can be sterilized at temperatures below 100°C.

2) Temperatures at 100°C:

a) Boiling – though highly unreliable as a sterilization technique and

more effective for disinfection, it is a very often used. Boiling water

in hot water sterilizes reaches 100°C and a time period of 10-30

minutes promotes sterilization. Sterilization may be promoted with

addition of 2% sodium bicarbonate. Most vegetable bacteria are

killed but sporing bacteria require longer periods. Advantages

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include rapidity, economy, no elaborate equipment, good penetration

and hardness to wide range of dental materials. Serious

disadvantage is that it dulls cutting edges and corrosion.

b) Steam at atmospheric pressure (100°C) : An atmosphere of free

steam is also used for sterilization. Koch or Arnold steamer or lab

autoclaves can be used. Live or free steam containers are of a tinned

copper cabinet with walls suitably lagged. The lid is conical,

enabling drainage of condensed steam and a perforated tray fitted

above the water level ensues material is surrounded by steam. A 90-

minute exposure is recommended media can be sterilized by this

process.

Steam is also used for frictional sterilization or tyndallization – John

Tyndall devised a process of sterilization by steaming for a few minutes at

100°C on 3-4 successive occasions separated by 24 hour intervals at room

temperatures. The principle is that the 1st exposure kills all vegetative

bacteria, spores will germinate and be killed on subsequent occasions. This

may fail in case of anaerobes in thermophilas.

3) Temperatures above 100°C:

a) Steam under pressure or compressed or saturated steam – saturated

steam under pressure is the most effective and practical method of

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sterilization and has been the standard method for many years. It is

performed using the apparatus called Autoclave. In these devices the

principle analyzed is that steam under pressure is hotter and the

higher the pressure, the higher the temperature. It works basically as

a pressure cooker. The autoclave basically has inlet valves for

steam, pressure gauges, temperature regulator and indicators,

listening down, safety, valves, and exhaust besides the main

sterilization chamber. Rapid advances and changing specifications

have characterized this device.

It utilizes temperatures in the range of 108 to 147°C. The regular cycle is at

250°F(120°C) for 15 minutes at 15 pounds of pressures. Flash sterilization

ca be achieved in 3-7 minutes at a temperature of 273°F(134°C) at 30

pounds of pressure.

Autoclaves may be manual or automatic and come in various sizes and

configuration. A majority of armamentarium can be sterilized by this

method. Precaution should be exercised in case of fluid to allow slow

subsiding of pressure to prevent boiling are or explosions. All terms for

sterilization must be dry and correct instrument load should be used. It is

preferable to give a “safe period” time-lag to allow thorough sterilization.

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The advantages include excellent penetration, short cycle time, relative

ease of use, wide range of materials indicated and economy.

The disadvantages are mainly corrosion and dulling of instruments along

with contraindication of heat sensitive material or materials impression to

moisture. The problem of common can be overcome by using ammonia,

dicyclobenzyl ammonium nitrite or yelohezylamiad decylamine. 2%

sodium nitrite is also effective.

Biological monitoring of moist heat-sterilization is via spores of bacillus

stereothermophilus and bacillus subtilis impregnated paper strips.

Chemical indications, autoclave layers and thermocouples are also used.

b) Next is unsaturated chemical vapor sterilization:

This system depends on heat, water and chemical synergism for its efficacy

and has the major advantage of greatly reducing corrosion of metal items

processed through multiple cycles. The temperature and pressure required

is greater than for an autoclave. Sterilization is performed in a chemiclave

(chemiclaving). Instead of distilled water, a solution of alcohol,

formaldehyde, ketone, acetone and water is used to produce the sterilizing

vapor. After preheating, packaged wraps that allow condensation of

chemical vapors are used. Chemicals operate at 270°F(131°C) and 20

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pounds pressure with a cycle lie of 20-40 minutes. Medial instruments used

must be dry prior to sterilization.

The major advantages include a short cycle time, no rusting or corrosion,

dry instruments at the end of the cycle and automatic preset cycle timing.

Since it has 8-9% vapor content, much less than the 15% minimum for

rusting and dulling, a myriad of items can be routinely sterilized without

harm to their structural integrity. Adequate ventilation, however is

important and permissible levels of formaldehyde should be monitored.

Also the vaposterile solutions use should be inspected.

Disadvantages include heat sensitivity of items, necessity of loading dry

instruments, chemical odors and constant vigil in use.

c) Also under the category come oil baths:

Hot oil bath have been used to sterilize metallic instruments. Oil can reach

a temperature of 175°C and an immersion time of 15 minutes complete

sterilization, however a 1 hour period is recommended. Oil has

disadvantages of poor sporicidal activity, being a fine hazard and being

difficult to remove.

Constant monitoring of all above methods is essential to ensure consistent

sterility.

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4) Radiation – Radiation can be ionizing, non-ionizing and lasers:

a) Ionizing energy are high energy electromagnetic waves including x-

rays gama rays, particulate radiations, cosmic rays and are highly

lethal with high penetrative power. This is a cold sterilization with

so heat involved. The lethal action is on DNA and indirectly through

water. Though more used individually, medically they are used for

hypodermic syringe sterilization.

b) Non-ionizing radiation – this includes infrared and ultraviolet rays.

Lethal effect is through generation of heat absorption and DNA

damage. Penetration is low but efficacy is high. Infrared is used for

rapid runs sterilization of syringes while UV is utilized for

disinfections enclosed areas such as entry ways, hospital wards,

operation theatres.

c) Lasers – These are the latest cutting edge modalities in sterilization.

Various types like CO2, Argon, Nd:YAG etc are used. Hoob and

colleagues found that exposure of instruments for 35 to a laser beam

is sufficient to sterilize. Further research and ongoing advances

could bring this technique into popular use in the future.

5) Ultrasonic and sonic vibration- cells of all kinds can be disrupted

by intense sonic and ultrasonic vibrations generated by

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magnetostrictive oscillation or piezoelectric crystals. Though

credited with bactericidal powers, result are variable. The method

have limited practical significance for sterilization but valuable in

disinfections and instrument cleaning.

6) Freezing: Freezing can both kill- pressure depending on various

factors. Super cooling to –106 –15°C freezes water in cells, cases

formation of ice crystals and subsequent thawing is also disruptive

to cell function. However, this is more often used for preservation of

microbes than destruction.

7) Filtration – Filtration has been used since time immemorial in

various forms. This is the method of choice for heat labile liquids

and solutions. Various materials and media are available for

filtration sterilization. They are also used to isolate specific involves

for study and culture. The various types of filters are:

1. Candle filters – Manlated in different grades of porosity, they

are widely used for water purilization for industrial and

drinking purposes. These are of 2 types a) unglazed ceramics

e.g. chamberland and doulton filters diatomaceous earth

filters e.g. Berkfeld and Mendler filters.

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2. Asbestos filters: Disposable, single use discs, they have high

adsorbing capacity and tend to alkanise filtered liquids.

Examples are Seitz, carbon and sterimat filters.

3. Sintered glass filters: Prepared by heat-fusing finely

powdered glass particles of graded sizes. Pore sizes are not

uniform. The passages larger than bacteria they remove.

Their effectiveness depends largely on adsorption of bacteria.

4. Membrane filters : These are made of cellulose acetate or

senile substance or esters. They are the most popular filters

used in purification and analysis, sterilization and sterility

testing and for preparation of solution for potential use.

Common pare sizes are 0.22 to 10µ but filters are produced

as small as 0.05µ. A 0.45µ size well prevent almost all

nonvisual microbes while that 0.005µ can strain out even the

smaller viruses.

5. More recent dislodgement is the nucleopore filter, a very thin

10µm poly carbonate film with etched holes and pare sizes of

0.1 to 0.8µ. High flow rates, low toxicity, chemical inertness

and resistance to damage are its desirable characteristics.

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After the physical agents, we shall now see the chemical agents used in

sterilization and disinfection.

A wide range of chemicals exist in use and some of the desirable

characteristics include wide spectrum of activity, high penetration and

effectiveness, compatibility, noncorrosive, non-toxic, safety and economy.

Firstly,

1) Ethylene oxide – this is considered, by many authors and agencies, as

the only time chemical sterilant while the others are considered merely as

disinfectant. Ethylene oxide is a gas at temperatures above 10.8°C, a highly

toxic compound that destroys by alkylation. It is the best method for

complex instrument and delicate materials. It is virucidal, sporicidal, does

not damage materials and evaporates without residue. Commercial

mixtures contain 12% ETO and 88% CFC or ETO and CO2 to reduce

flammability. Different materials may require different cycles but 10-16

hours is the norm with variable time periods for degassing to prevent

adverse effect with the gas. Items should be clean and dry and specially

built autoclaves may be used. Concentration of 500mg of gas/ litre at 58°C

and relative humidity of 40% reduce time to 4 hours. Varying these factors

can increase the effectiveness manifold.

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Advantages include high penetration, no damage to heat sensitive and

complex devices, evaporation with no residue. Disadvantages are its

slowness, toxicity, dry instrument to be used, flammability of material and

degassing required.

2) Aldehydes – Glutaraldehyde and Formaldehydes: These are also

considered acceptable sterilants. Formaldehyde is a highly irritating gas. It

is a strong reducing agent and inactivates enzymes and amino groups of

protein. For best results, a relative humidity of about 70% and temperature

of 22°C are required. It has low penetrability and high toxicity, being

markedly sporicidal bactericidal and virucidal. Used to pressure specimens

and sterilize clean metal instruments. The gas is used for sterilizing

instrument and heat sensitive catheters as wlel as fumigation. Ammonia

vapor is used to counteract the irritant effect of their agent.

Glutaraldehyde has a similar action to formaldehyde and are specifically

active against tubercle bacilli, fungi and viruses. It is less toxic and irritant

then formaldehyde. Commercial preparations are active at different pH and

have percentage of 2.0 to 3.2%. They can destroy microbe in a 10 hour

impression period. They have a surprising resistance to inactivation by

organic matter and do not harm rubber and plastic hence being indicated

for impression materials. They may corrode or dicolor metal if mixed.

Their shelf life, use and reuse life should be noted. Their main

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disadvantages are their toxicity and irritation and physical contact with

these solutions should be avoided.

3) Beta-Propiolactone (BPL): This is a condensation product of ketone

and formaldehyde with a boiling point of 163°C 0.2%. BPL is used for

sterilization and is effective against all microbes and viruses. It act by

alkylation. A relatively humidify of 70-80% at an temperature of 25°C with

a final concentration of 2-4mg/L requires an sterilization time of 2-3 hours.

It is more efficient then formaldehyde in fumigation but is carcinogenic

too. It is also used to sterilize vaccines, graft tissues and other delicate

biological material.

Now we shall look at chemicals used exclusively as disinfectants and

antiseptics:

1. Alcohols : Ethyl and isopropyl alcohol have been used

traditionally. They were used mainly as skin antiseptics and

act by denaturation bacterial proteins. They are not effective

on spores. A concentration of 60-70% in water is used.

Methyl alcohol is effective agent fungal spores is used in

cabinets and incubators. Alcohol must have prolonged

contact to be effective. Disadvantages include rapid

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evaporation, dehydration, corrosion and ineffectiveness

organic media.

2. Surface active agents: (Detergents) substances which alter

energy relationship at interfaces producing a reduction of

surface or interfacial tension are referred to as surface active

agents. They are used as wetting agents, detergents and

emulsifiers and are classified into 4 main groups namely

anionic, cationic, nomionic and amphonic. The most

important are the cationic surface active agent. They act on

phosphate groups and denature proteins. Different groups

are:

a. Soaps – Active against spirochetes, streptococci, and

other microbes. Used most commonly as hard wash

agents due to surface tension reducers and

detergents.

b. Synthetic detergents – synthesized commercially,

they are markedly microbicidal and are anions and

used for humidies.

c. Quaternary ammonium compounds – these are the

cationic surface active agents. Benzalkonium

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chloride is most commonly used. Primarily active

agent gram positive bacteria and is well tolerated by

tissues. Cetyl trimethyl ammonium bromide

(ceteferol) is another one used. However, they

cannot penetrate organic debris, not sporicidal or

virucidal. They are good cleansing agents and are

used as such:

d. The amphotonic or ampholytic compound known as

Lego are active against a wide range of gram

positive and negative organisms and viruses. They

however, are not in general use.

3. Hexachlorophene – Used for surgrical scrubs and

preoperative preparation. Particularly effective against gram

positive organisms. It has substantitivity action but is used

sparingly now.

4. Dyes – 2 groups of dyes – aniline and acidine dyer are used

extensively as skin and wound antiseptics. Aniline dyes are

brilliant gram, malachite green and crystal violet. More

effective against gram positive. They are non-irritant and non

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toxic. The lethal effect is due to a reaction with acid group in

the cell.

Acridine dyes are more active against gram positive. Important

ones are proflamie, acriflame, euflamie and aminamia. They

impair DNA complexes and kill or destroy reproducitivity of the

cell. Used in gauge impregnation.

5. Oxidants : Commonly used are hydrogen and metallic

peroxidase. Hydrogen peroxide is frequently in treatment of

anaerobic infection. Zinc peroxide is another variant.

6. Phenols and its derivatives: The classic antiseptic for

surgical procedures was carbolic acid introduced by Joseph

Listr in 1850s phenolic compounds have since arrived. They

act as cytoplasmic poisons and have high penetration. The

various types are:

a. Phenol- Bactericidal at 1% and fungicidal at 1.3% it

is seldom used now, but is the standard of

comparison for other disinfectant.

b. Hexyl resorcinol – used widely, specifically as a

antihelanthic and in commercial mouth washes.

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c. Cresols – Alkyl derivatives of phenol composed of

ortho, meta and para cresol. Here greater

tuberculocidal activity and used for disinfection of

floors and walls.

d. Halogenated phenols – they are active germicides.

Camphorated p-chlorphenol used as a root canal

antiseptic. PCMX (Parachlorometaxylenol) is a

halogen substituted phenol employed in hand wash

antiseptics. It is bactericidal and fungicidal..

e. Bisphenols – Hexachlorophere and chlorhexidine

have high bacteriostatic properties. Used as skin

antiseptics, they demonstrate substantivitiy. They are

not effective against tubercle birth.

f. Complex synthesis phenols: These are constraints of

2 or 3 phenols acting synergistically to produce

asepsis.

g. Orthophenylphenol similar to hexachlorphores, used

as irrigation solutions in surgical wounds.

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7. Heavy metal compounds: All metal ions inhibit microbes in

sufficient concentrations but a few are useful as antiseptics

and disinfectants. Metals inhibit nonsporulating bacterias by

oligodynamic actions. They have a high affinity for proteins

especially the sulphydryl groups and gel readily absorbed.

Asrenic compounds were the first areas used other include:

a. Mercury compounds: Mercury bichloride and

chloride are used as skin antiseptics mebromin is

used as an antiseptic and various ointments. Mercury

poisoning has discouraged their use.

b. Silver compounds – simple silver salts like silver

nitrate, silver lactate and pirate are used as

antiseptics 1 to 2% solutions are used.

c. Copper sulphate and zinc compounds like zinc

sulphate are also used especially the latter in skin

asepsis.

8. Chlorine and its compounds: The halogen chlorine precisely

acts against microbial forms by oxidation, as hypochlorous

acid. Elemental chlorine kills most bacteria in 15-30s at 0.1

to 0.25ppm. It has been used since 1774. commonly used

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compounds are hypochloride solution and chlorine dioxide

preparations. Diluted sodium hypodiute (1:10) in water is

very useful for disinfection especially for hepatitis virus,

CDC has recommended 500-5000ppm. Being unstable, fresh

solution should be prepared daily through same newer

formulae have tried to offset this. Other dead stages include

corrosion and irritative nature.

9. Iodine and iodophors: It is one of the oldest skin and wand

halogen antiseptics. Its high reactivity gives it potent

germicidal effects. It acts by iodination of proteins. Being

insoluble in water, it is used as a tincture i.e. dissolved in

alcohol. Drawbacks are irritation, allergenicity, corrosion and

staining as well as hypersensitivity.

Iodophors are preparations in which iodine is held in dissociable

complexes and have a broad antimicrobial spectrum but are less irritating,

non staining and have stained activity, common carries used are polyvinyl

pyrolidine (PVP) and ethylated polyoxamers. These release iodine slowly

as well as are surface acting agents improving penetrability. They are also

used as skin antiseptics and hospital disinfectants in concentration of

200ppm. Solutions are unstable and should be diluted with distilled water.

Common preparations are iodide and betadine.

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Monitoring of sterilization and disinfectants:

An integral part of the sterilization process is its efficient monitoring. A

periodic verification (at least weekly) should be integrated into the

sterilization progress.

Monitoring can be chemical and biological:

Chemically treated tapes and other heat sensitive indications that change

color generally inform the practitioner that sterilization conditions have

been reached. However, these are not perfectly reliable as they change

color much earlier too with autoclave tapes being notoriously unreliable.

Heat sensitive indications consist of paper strips, labels and steam patterns

cards impregnated with chemicals designed to change color on heat and /

or chemical exposure. Chemical formulations may be sensitive to myriad

factors like time, temperature and saturated steam simultaneously.

Indications can detect gram process malfunctions quickly.

Biological monitoring in the form of calibrated biological indicators

remain the main guarantee of sterilization. These preparations contain

bacterial spores more resistant to heat thus viruses and vegetative bacteria

with color indicators. Bacillus stereothermophilus and subtilis are

organisms often used. These provide must reliable sterilization monitors.

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Thus a combination of the 2 should be used for clinical needs. Evaluation

of disinfectants – Disinfectants are usually strong, mild or weak and are

evaluated by the phenol coefficient determination where phenol is the

control, use dilution test, inactivation tests and specific filter testing for

gaseous disinfectants are should follow guidelines and be regularly

monitored.

Now we come to the specific considerations and applied aspects in

dentistry:

Firstly,

The dental chair and delivery system. The chair should be smooth and

seamless. The greatest potential for cross contamination is from chair

mounted controls. Disposable covers should be used as for as possible and

should be lipid with any of the acceptable above described disinfectants

between patients.

The delivery system has a myriad panel susceptible to infection retention

and spread. Control should be seamlessly integrated or can be remote

controlled. Cart tops should be smooth and preferably separate. The entire

unit should be covered with disposable covers where possible and

disinfected and wiped between patients on exposed surfaces.

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Also included are the task seating surfaces and foot controls. The dental

operators chair or stool should be of breakable materials or high quality

sheepskin or vinyl plastics. They can be covered with disposable materials

and disinfected between uses. Foot control too should be routinely

disinfected with the may available agents described.

Next come the X-ray unit – an integral part of all practices it is subject to

heavy contamination. Single disposable plastic wraps minimize infection

spread. Also disinfectants can be used on the surfaces. Film holders, bite

blocks and the processing unit which are all subject to high contamination

should be routinely disinfected and sanitized.

Also, cabinets and work surfaces should be kept to a minimum and should

be simple in design. Sinks should be stainless steel or porcelain with foot

or electronic controls. Materials should be orderly assayed and all cabinets

should be routinely wraped down to limit infection.

Tubings and hoses including suction and delivery hose can harbor

infection. All surfaces should be smooth and without crevices. Ideally they

should be removed and sterilized. Suction systems should be routinely

closed with water and disinfectant while hand piece and air water syringe

tubings should be in enclosed retractions devices. Outer surfaces with the

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connector assembly should be washed with detergents and disinfected by

immersion.

After this we shall have a look at handpiece sterilization and asepsis. The

handpiece is a delicate and highly specialized equipment that is literally an

extension of the dentist’s personality and professional expertise proper

speed, need size, chuck, hose and connector and handpiece lighting should

be considered. Disposable handpieces are the ultimate in high teeth

sterilization.

Hand piece contamination is natural and multifaceted. It occurs by

contamination of external surfaces, turbine chamber contamination, water

and oral fluid retraction, water line contamination and spatter and aerosol

generation.

Hence handpieces should be thoroughly sterilized. External surfaces should

be cleansed and after proper lubrication methods of sterilization like

autoclaving or chemiclaving can be used for modern sterilizable

handpieces while ethylene oxide and chemical sterilize are recommended

for contraangles and non-heat sterilizable systems. Careful manufacturer

institution should be adhered to avoidable chemicals include

glutaraldehyde as they may dense the assembly and be subsequently toxic

to tissues. Hand pieces should be storaged between patients and hence a

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through knowledge of them mechanics should go into their purchase.

Common brands like KaVo, Midwest, Star etc use specified lubricants and

can withstand autoclaving sterilization.

Next come the water system asepsis – water line asepsis should be a

factor considered in the clinic firstly water and oral fluid fraction should be

avoided using antiretraction valves, repositioning of internal ‘O’ rings or

upgrading versions. Periodic checks should be made secondly water lines

should be cleansed for a minimum of 20-30s between patients and running

disinfectants regularly through them microbial biofilm contamination of

dental waterlines is a reality and can be limited by use of regular cleansing

and disinfectants like iodophore or diluted sodium type chloride. Biocide

solutions, filters, and dedicated water systems for infection control are

recommended.

Now lets see infection control for impression and related registration –

different impression materials will withstand various disinfection

procedures. Impression and related materials should be properly closed and

treated with an appropriate disinfectant as shown. Prosthesis and

appliances should also be disinfected and rinsed as should casts. Some

properties (like increased hardness with glutaraldehyde) are actually

improved. Dental laboratories whether in clinic or outside should also

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follow decontamination procedures hardly materials as biohazardous and

using aseptic precautions in their processing.

Lastly, a small look at recommended and available procedures for

sterilizing and disinfecting specific dental armamentarium. Burs for

e.g. can be autoclaved, dry heated, chemiclaved or chemically sterilized.

Endodontic instruments sterilize well with salt / glass bead sterilizers.

Plies, cements spatulas etc can be flamed. Metal instruments ca be

autoclaved or dry heated or chemically sterilized. Glass slabs and dappen

dishes may be chemically sterilized with thimerosal (merthiolate) while

gutta percha can be sterilized with sodium hypochlorite impression can be

disinfected with glutaraldehyde or other chemicals while claps and stones

can be heat sterilized. Various other items are shown in the table. Also note,

numerous items are recommended for disposable use in a single use and

throw fashion. Disposable equipment should be used where practical and

feasible. Also barrier methods and plastic or other disposable covers should

be used for complex devices or straight surfaces like light are units to

optimize infection control procedures. Remember when anything can be

sterilized, do it.

Another specific consideration is the universal precaution to be employed

in treating known infection patients. Along with straight personal barrier

protection, use of disposables and of artificially sterilized units should be

40
mandatory. Special considerations should be made in use of HIV and

hepatitis infected patients. Vaccination for hepatitis should be compulsory.

Barrier techniques the double gloving etc should be used. Sharps should be

ultra cautiously handled and disposable kits and armamentarium should be

performed. Stringent sterile precautions are called for while dealing with

known infectious cases so as to maintain absolute asepsis in the operatory

and ensure protection to personnel and patients.

CONCLUSION:

“Prevention is better than cure”. A proverb so well suited to sterilization

and asepsis. A thorough understanding and application of the intricacies of

sterilization will help ensure safety from the invisible but deadly world of

microbial pathosis and assist the practitioner in delivering holistic care with

maximal efficiency ensuing happy and healthy patients, personnel and

physicians themselves.

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