Complete Guide to Sterilization in Orthodontics

STERILIZATION
IN
ORTHODONTICS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


1

INTRODUCTION
 Infectious diseases have scourged the
world throughout history.
 Even today, infectious diseases have
been discovered at a rate of one disease
per year over the past 22 years.


2

 As the old saying goes "Prevention is
better 'than cure".
 Such universal precautions must be both
comprehensive, to prevent infection
transmission in all clinical situations,
and realistic, to allow convenient
provision of dental treatment.


3

HISTORY
 The belief that disease was a result of
human wrong doings was common and did
not change until the causes of disease and
disease transmission were investigated.
 Girolamo Fracastorius - Existence of tiny
living particles that cause contagious
disease being spread by direct contact
with humans and animals and by indirect
contact with objects.

4

 Antony Van Leeuwenhoek who is considered
"Father of Microbiology“ studied the debris
surrounding teeth and was the first to observe
bacteria using a crudely built microscope.
 Sammelweis in Vienna and Holmer in U.S.A.
first recognised the importance of hand washing
in preventing the spread of disease agents.


5

TERMINOLOGIES
 ASEPSIS
The absence of infection or infectious materials or
agents. (Miller)

 INFECTION
Infection is the multiplication and survival of
microorganisms on or in the body. An infection does
not always indicate disease, but disease seldom results
Without infection. (Miller).

 INFECTION CONTROL
Infection Control is the prevention of multiplication
and survival of microorganisms on or in the body of
living and non living objects.
It is the sum total of all the measures taken to prevent
subsequent infection

6

STERLIZATION
 It is defined as the process by which an article,
surface, or medium is freed of all
microorganisms either in vegetative or spore
state. (Panikar)
 Denoting the use of physical or chemical agents
to eliminate all viable microbes, including all
bacteria, viruses and spores. (Jerry R. Mc Ghee)
 Sterilization is the process designed to kill
bacterial spores, therefore its intended use is to
kill all microorganisms. (D.C.N.A. 1991)

7

DISINFECTION:
 Disinfection means the destruction of all
pathogenic organisms or organisms capable of
giving rise to infection. (Paniker)
 Disinfection is a less lethal process intended to
kill disease producing microorganisms but not
bacterial spores (D. C. N. A - 199 1).


8


9


10

MICROORGANISM
Hepatitis B (HBV)
Hepatitis C (HCV)
Hepatitis D (HDV)
Herpes simplex type I

DISEASE
Hepatitis B
Non -a non-B, hepatitis
Delta hepatitis
Oral herpes, Herpetic
Whitlow ,Herpatic keratitis

Herpes simplex type II Genital herpes
HIV
AIDS & ARC
Neisseria gonorrhoeae
Gonorrhoea
Treponema pallidum
Syphilis
Pseudomonas aeruginosa Wound infections, abscesses
Wound infection, abscesses
Staphylococcus aures
Clostridium tetaniwww.indiandentalacademy.com
Tetanus

11

Micro organisms transmitted by
inhalation
Micro organism

Disease

Varicella virus
cytomegalovirus
Measles (rubeola)
Influenza virus
Rubella virus

Chicken pox
Infections in infants
Measles and mumps

Myobacterium tuberculosis

Influenza and common cold

German measles
Tuberculosis

Sterptococcus pyogens

Oral abscesses, rheumatic
fever & endocarditis

Candida albicans

candidosis

12

Transmission of Infection
Infection transmission during dental
procedures is dependent on four factors:
 Source of infection
 Means of transmission
 Route of transmission
 Susceptible host

13

SOURCE OF INFECTION
SOURCE

Patient
suffering
from
acute infections

Patients in
Prodromal stage
of infection

carriers

Known carrier

Unknown carrier

14

How dental staff acquires
infections
Injuries caused by contaminated
instruments
 Injuries caused by contaminated
instruments may create a portal of entry for
pathogenic micro-organisms. If the number
of micro-organisms introduced by this
route exceeds the infective dose, infection
may result.

15

Risk of infection following needle
stick injury
 The estimated blood on a needle stick is
about 1.4µL and the amount required to
cause an hepatitis or HIV infection is about
0.1µL and the incidence of infection is
about 20 -25%after needle stick injury.


16

Existing lesions on the operator's
hands
 The incidence of HBV infection among the
dental profession is about five times higher
than in the general population.
 Members of the orthodontist’s team who
operate ungloved are at risk.


17

Dental aerosol
 Aerosol is defined as small droplets,
usually 5 µ or less in diameter, which can
remain suspended in air for some time.
 Mycobacterium tuberculosis has been
detected in dental aerosols and there is an
increased incidence of tuberculosis in
dental professionals.

18

Splashes of contaminated sharp
material
 When operating the turbine hand piece,
particles over 0. 1 mm in diameter are
dispersed up to 6 meters at speeds of 50-60
km.
 It has been suggested that hepatitis B and
herpes simplex type I can be transmitted
by these means

19

How does the patient acquire
infection
 Lesion on the operators ungloved
hands
 Contaminated gloves or hands
 Contaminated instruments and other
dental equipment.

20

Manifestation in dental health care
workers

HERPETIC WHITLOW (due to ungloved hands)

HERPETIC KERATITIS(caused by contaminated
aerosols)

21

CATEGORIZATION OF
INSTRUMENTS
 Critical instruments
 If an instrument will
be used to penetrate
tissue or to touch
bone it must be
sterilised.


22

Semi-critical instruments
 Semi-critical
instruments: mirror,
probe, and tweezers.
 If an instrument will
touch mucous
membranes, but will
not be used to
penetrate tissue or to
touch bone,it should
be sterilised.

23

Non-critical instruments
 These are defined as
equipment and
surfaces which
contact only intact
skin, such as mixing
slabs and spatulas.


24

Hand Washing
 To destroy pathogenic micro-organisms which
collect on the hands
 To prevent blood which contains pathogenic
micro-organisms


25

Mechanical removal of debris and
of transient micro-organisms
 Rubbing removes micro-organisms from
the skin.
 Lathering holds them suspended away
from the skin's surface.
 Rinsing washes them off the hands.

26

Disinfection
 The disinfectant action of hand washing
will destroy in situ micro-organisms on the
surface of the hands.


27

Hand scrubs and hand washes
Properties
 Act fast
 Not irritate the skin after repeated
use
 Have a broad range of bactericidal
and residual activity.


28

Antiseptics used in hand washing
Chlorhexidine
 This is 2-4% chlorhexidine gluconate with 4%
isopropyl alcohol in a detergent solution with a
pH of 5.0 to 6.5.
 More effective than povidone iodine
POVIDONE IODINE
 These products contain 7.5% to 10% povidone
iodine providing 0.75% to 1.00% available
iodine.

29

Phenolic compounds
 Hexachlorophene
 Can be absorbed into the blood stream
through intact skin, although it is more
readily absorbed through abraded skin. It
may be toxic if the blood concentration
rises with repeated exposure.
 Parachlorometexylenol (PCMX) is
bactericidal and fungicidal at 2%
concentration. It is not toxic.

30

ALCOHOLS
 Ethyl alcohol and isopropyl alcohol are widely
used as topical skin antiseptics, and have a potent
bactericidal effect, especially at 70%
concentration.


31

PROCEDURE FOR HAND WASHING


32


33

Elbow taps should be used
and clean tissue should be
used for wiping


34

Personal hygiene
 Facial hair should be covered with a face
mask
 Hair should be short or kept away from the
face.
 Jewellery should not be worn on the hands
or arms during clinical sessions.
 Nails must be kept clean and short.

35

Personal Protection
 Barriers considered essential when
performing all dental procedures are:
 Gloves
 Masks
 Protective eyewear


36

Gloves
The main types of gloves used in dentistry
are:
 Latex gloves: non-sterile and sterile
 Vinyl gloves: non-sterile and sterile


37

Latex gloves
 To protect patients from becoming infected
with micro organisms on the operator's
hands.
 To protect the operator and staff from
microorganisms present in the patient's
blood and saliva

38

Non-sterile latex gloves
 Examinations
 Routine restorative procedures
 Prosthetic and endodontic treatment
 Prophylaxis Radiography Laboratory
work.


39

Single use versus re-use

Repeated use of one pair of gloves with
disinfection between patients is not advisable for
the following reasons


40

Double gloving
 Double gloving
reduces the risk of
puncture.
 The enhanced safety
has to be balanced
against the discomfort
or reduced dexterity.


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43


44

Orthodontist's gloves
 The risk of glove puncture is high for
orthodontists, who repeatedly handle wire
bands and ligatures.
 Orthodontist can use puncture resistant
gloves which are thicker at the palm, a
high stress area for ligature placement and
thinner material at the finger tips.

45

Masks
 Aerosols and splatter
 Aerosols are generated by turbine handpieces,
air/water syringes, and ultrasonic scalers.
 Droplets of blood are also splattered over the
face during dental procedures, and these may
contact existing skin lesions or skin damaged by
sharp, flying debris.


46

Properties of an ideal mouth
mask
 It has a bacterial filtration efficiency of
95% or more
 It does not contact nostrils or lips
 It has both high filtration of small particles
 Close fit around the entire periphery
 It does not cause fogging of the eye glasses

47

The nose piece of the fluid shield mask

48

Eye Protection
Causes of eye damage
 Sharp particles projected at speed from the
mouth when using the turbine hand piece,
ultrasonic scaler, and air/water syringe
may cause eye injury
 Blood/saliva droplets may enter the
operator's eyes and may transmit infection.

49

Protective glasses with side pieces

A chin length face shield
which protects the whole face

Disposable with a www.indiandentalacademy.com
plastic face shield

50

LIMITING CONTAMINATED
AEROSOLS AND SPLATTER
 Pre treatment brushing and use of a pre
treatment mouth wash
 High velocity aspiration
 The use of rubber dam
 Efficient air filtration and ventilation

51


52

Protective clothing
 To protect street clothes from contamination,
wear a uniform or cover with a gown or coat.
 Contaminated clothes should be washed at 80ºC
for 10 mins using a strong detergent and bleach if
possible
Sleeves
 Long-sleeved uniforms are recommended. Tuck
the bottoms of the sleeves into the gloves

53

Tuck bottom of sleeves into the gloves

54

Footwear
 A pair of smooth, slip-on shoes should be
kept exclusively for use in the surgery.
These should be cleaned at the end of each
clinical session.
Head covers
 Head covers provide an effective barrier.


55

Covering surfaces
Surfaces can be covered with
 Clear plastic wrap
 Aluminium foil
 Paper with impervious backing
 Commercially available ,polythene sheets and
tubing


56


57

Surface disinfection in case
covering is not used


58

Recommended surface disinfectants
PRODUCT

DILUTION

RECOMMENDE
D TIME

SODIUM
HYPOCHLORIT
E5.25%
(BLEACH)

1:10

10 mins

IODOPHORS
Biocide
Surf-a-cide

1:213

10 mins

COMBINATION
SYNTHETICS
Phenolics
Multicide
Omni II
Vitaphine

1:32

10 mins


59

 All these materials have the disadvantage
of leaving surfaces wet for 10 minutes,
which is inconvenient in a busy dental
practice.
 Glutaraldehyde products that are intended
to be used as surface disinfectants contain
only 0.25% (w/v) glutaraldehyde.


60

Disinfection of small surfaces
between patients
 Preclean, using the spray-wipe technique,
with a recommended pre cleaning solution
or water and detergent.
 Spray with a product containing 70%
alcohol, plus a low concentration of
synthetic phenolic. Leave this solution on
the surface for 3 minutes.

61

Spillages
 Cover the spillage with
Virkon powder or
Presept granules and
leave for 3 minutes
 Remove the residue
using strong paper
towels soaked in
disinfectant (sodium
hypochlorite or
Virkon) and place these
in a disposal bag.

62

Disposables
 If an instrument or item cannot be satisfactorily
sterilized or disinfected, then choose a disposable
alternative.
 If an instrument or item can be appropriately
sterilized or disinfected quickly, efficiently, and
with minimal damage, do, not use the disposable
alternative unless it is very cheap and of similar
quality.

63

 Anaesthetic needles and cartridges
 Mouthwash Cups/beakers
 Saliva ejector tips
 Intra-oral radiograph holders
 The patient's protective bib
 Surgical masks
 Operating gloves
 Disposable impression trays
 Prophylactic Polishing cups and brushes

64

VARIOUS TYPES OF DISINFECTANTS
AND THEIR USES
CHEMICAL USED

APPLICATION

Chlorine compounds

Surface disinfection

Iodophors

Surface disinfection

Combination synthetic
phenolics

Surface disinfection &
immersion disinfectant

2%glutaraldehyde

Surface disinfectant &
high level immersion
disinfectant


65

Instrument Arrangement and
Packaging


66

The advantages of using trays
 Allows instruments to be set up in an
organised way.
 Restrict gross contamination to a surface
which can be cleaned and sterilised
 Provide safe, aseptic storage (pouches and
paper wraps may be penetrated by sharp
instruments).
 Trays are particularly useful for sets of
larger instruments.

67

Sterilisation Pouches
 Pouches are very useful for the sterilisation and
aseptic storage of single instruments
 Each pouch should be flatted by hand, to drive
out most of the air, and must contain a chemical
time/temperature indicator strip.


68

Clear view pouches with TST strips


69

Sterilisation of Instruments
 There are four distinct stages which
achieve safe instrument sterilisation:
 Pre-cleaning disinfection, using 'holding'
solutions.
 Pre-sterilisation cleaning.
 Sterilisation.
 Aseptic storage.

70

STERILIZATION AREA

71

Pre-Sterilisation Disinfection
 After use, Place instruments into a disinfectant
detergent solution in a container located within
the operating zone near to the dentist.
 At the end of the dental procedure, take the
container to the sterilisation area. Thoroughly
rinse the instruments with water. The solution
should be discarded daily.
 A synthetic phenolic solution diluted 1:32, is
an ideal holding solution

72

PRE STERILISATION CLEANING
 Proteinaceous material protects microorganisms on the surface of instruments
from heat and other sterilisation
conditions. Pre-sterilisation cleaning may
be achieved in one of three ways:
 Hand scrubbing
 Ultrasonic cleaning
 Dishwasher instrument cleaning.

73


74

Sterilisation
 Instruments must be clean and dry before
sterilisation.
There are four types of sterilisers used
routinely :
 The steam autoclave.
 The chemical vapour pressure steriliser.
 The dry heat oven.
 The glass bead/salt steriliser.

75

THE STEAM AUTOCLAVE
 A steam autoclave sterilises by the use of steam
under pressure. Non-vacuum autoclaves are used
in dental practice.
 A prescribed temperature, pressure, and time are
necessary to destroy bacterial spores. The faster,
higher temperature cycles are generally favored
by dentists in general practice.


76

Chemical vapour sterilisers
 Chemical vapour sterilisers operate by heating a
deodorized alcohol, formaldehyde, and ethyl
methyl ketone solution, which can be obtained
from the manufacturer, to 132ºC at 138-276 kPa
(20-40 lb/in2) for 20 minutes in a closed
chamber.


77

Instruments suitable for sterilisation
with chemical vapour
 All dental hand instruments.
 Orthodontic wires and bands.
 Orthodontic pliers


78

Dry-heat sterilisers
 Convection heat has become a popular means of
sterilisation of instruments for orthodontic
offices.
 Dry heat is an effective means of sterilisation,
when it is used properly. Unwrapped, moderate
loads of instruments placed in an oven can be
sterilised at 160-170ºC in I hour.

79

HOT AIR OVEN

80

GLASS BEAD STERILIZER
 To have an effective sterilization one has to have
many sets of instruments where single use is
possible after sterilizing them in a hot air oven, or
one has to wait for long enough to have
effectively sterilized in between appointments.
 So there is acute necessity in the orthodontic
office set up, where instruments can be sterilized
quickly and rapidly.


81

Conventional

Customized glass bead glass bead sterilizer
sterilizer for orthodontic
instruments
82

Disinfection of impressions
 The most commonly used impression
material is alginate and these impressions
are highly infected when removed from the
patients mouth


83

Recommended Procedure for
disinfecting the alginate impression
 Rinse the impression thoroughly under running
tap water, shake the impression to remove excess
water.
 Dip the impression in a 1:10 solution of sodium
hypochlorite for several seconds to ensure
maximum contact of undercut with the
disinfectant.


84

 Wrap the impression in gauze soaked in
1:10 sodium hypochlorite, place in a
plastic bag and seal for 10 minutes.
 Remove the impression and rinse
thoroughly under running tap water.


85

Visible-light curing units
 Some new designs of unit feature removable,
autoclavable light curing tips. However, the
handles still present a problem, since they cannot
be sterilised.


86

 Units: Should be cleaned and disinfected
with a phenolic disinfectant after use.
 Plastic units should be disinfected using
an iodophor.
 Glutaraldehyde disinfectants have been
found to damage the glass rods in a fiberoptic light tip, with a subsequent reduction
in light output; the use of this disinfectant
should be avoided.

87

Monitoring sterilisation
 Tests using chemical indicators
 Test strips or tubes are available
for autoclaves, chemiclaves, and
dry-heat ovens
 Several types of colour-change
strips or tapes indicate
temperature change only, that is,
they only show that the load has
been in a heat steriliser.


88

Biological Monitors

 Bacillus stearothermophilus
is used for chemical vapour
and steam sterilisers, and B.
subtilis is used for dry-heat
spore testing.


89

Disposal Clinical Waste
 Used disposable
scalpels, anaesthetic
cartridges, used burs,
orthodontic wire,
extracted teeth, and
other sharp objects
should be carefully
dropped into a solid
puncture-resistant
container


90


91

CATEGORY OF WASTE

CONTAINER

CAT
I

Blood body fluids bandages,
microbiology,& biotechnology
waste, extremely soiled lining

Tubes ,buckets Yellow
with lids

CAT
2

Sharps
Reusable sharps such as needles
scalpels surgical instruments
Waste sharps such as broken glass
disposable needles broken blades

Stainless steel

White or
translucent

Card board
boxes

Blue

CAT
3

Disposable plastics gloves

Bgs or buckets
stain less steel
drums

Red

CAT
4

Chemical waste

Buckets with
Black
lids ,card board
cartons

CAT
5

Compostable waste

Buckets and
drums


COLOUR

Green

92

SUMMARY
 In every health profession the guiding principle is
“DO GOOD BUT DO NO HARM” is as
HARM
applicable today as it was in the time of
Hippocrate.
 Sterilization in orthodontic office is an important
exercise, due to unabated spreading of HIV virus,
hepatitis viruses, there is a great concern
regarding the sterility of orthodontic instruments.


93

WHICH IS THE IDEAL
METHOD ?
 The ideal method for sterilization should
be economical , less time consuming ,with
low maintenance cost , require minimum
space and infrastructure and the method
which complies by all these requirements
is a GLASS BEAD STERILIIZER


94


95

Complete Guide to Sterilization in Orthodontics

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