Asepsis & Sterilization Antisepsis- Procedure or application of antiseptic solution which inhibits the growth of microorganisms, while remaining

in contact with them, but does not necessarily imply sterility. Eg scrubbing up Disinfection- It is a process which reduces the number of viable pathogenic microorganisms to an acceptable level but may not inactivate some viruses and bacterial endospores. Sterilization- It is the process of destruction or removal of all microbial forms. Antiseptics are used on living tissue, whereas disinfectants are used on inanimate objects. Types: A. HEAT STERILIZATION 1. Moist <100 deg C- Pasteurization, > 100 deg C- Autoclaving Autoclave- 121 deg C (250 deg F) 20 min at 15lb pressure or 134 deg C (273 deg F) 3 min Kills by coagulation & denaturation of proteins Efficiency tested by spore testing (Geobacillus Stearothermophilus strip), thermocouple, Browns Test (chemical red amber green), Autoclave Tape/ Bowie Dick test To minimize corrosion: add ammonia to autoclave, dicyclohexyl-ammonium nitrate, 2% sodium nitrate Boiling water sterilization 100 deg C for 10 min 2. Dry Acts by dehydration and oxidation 160 deg C (320 deg F) 2 hrs Used for lab glassware, glass syringes, instruments 3. Gas Sterilization Ethylene oxide gas at temperature above 10.8 deg C , destroys by alkylation and denaturation of nucleic acids of microorganisms, toxic/ flammable/ irritant/ mutagenic/ carcinogenic. Used for electric equipment, endoscopes, handpieces Needs time to degas the plastic equipments- 1-7 days Low Temperature steam and Formaldehyde (Chemical vapour) , destroys by double action heat & chemical (alkylation of proteins), 127-132 deg C at 20-40 psi for 30 min. Used for heat sensitive equipment and plastic 4. Irradiation

IONIZING RADIATION X rays, gamma rays, high speed electrons To sterilize needles, syringes, swabs, culture plates, catheters, suture material, cannulas, pharmaceuticals, Uses Cobalt 60, effects DNA of nucleus

NON- IONIZING RADIATION Ultraviolet: low penetration, used to purify air in operating rooms Infrared: purify syringes, operating room, for preparing immunizing agents by attenuating viruses/ bacteria

5. Cold/ chemical sterilization Formaldehyde: to sterilize suction pumps/ ventilators Glutaraldehyde: against TB bacteria, HPV, HBV , spores, fungi etc, 2% glutaraldehyde (Cidex) 20 min for disinfection, 6-10 hours for sterilization Diguanides (Chlorhexidine, for Staph aureus, gram neg bacteria but not spores/ fungi/ virus, Chlorhexidine cetrimide --- Cetavlon/ Savlon 4% Chlorhexidine detergent --- Hibiscrub ( post op scrub) 2% - surgical scrub, and as a pre-operative skin preparation
0.12% -0.2%--- dental use It has both bactericidal and bacteriostatic mechanisms of action, the mechanism of action being membrane disruption.

6 % hydrogen peroxide Hypochlorite eg Sodium hypochlorite 5.25- 6.15 % environmental disonf, dental impression/ cast- 0-2 % Alcohols, denature proteins to act, 70% more effective as water speeds up denaturation, ethanol (70%), isopropyl (60-70%) Benzalkonium chloride: both as disinfectant & antiseptic Hexachlorophene compounds- for surgical prep in patients sensitive to iodine Iodophores: Effect against bacteria, spores, viruses Tincture of iodine or iodine tincture is an antiseptic, it is also called
weak iodine solution. Usually 27% elemental iodine, along with 5% potassium iodide or sodium iodide, dissolved in a mixture of 85% ethanol and water. The role of iodide and water in the solution is to increase the solubility of the elemental iodine, by turning it to the . soluble triiodide anion I3 This was locally toxic and caused burns.

Povidone iodine (PVP-I) results from the combination of molecular iodine and polyvinylpyrrolidone. Slow release of iodine from the PVPI
complex in solution minimizes iodine toxicity towards mammalian cells.

For wounds-10%

Surgical scrub-7.5% Spray, ointment for ulcers/ burns- 5% Gargles- 0.5-1%

Some Facts: Effect of antiseptics increases with rise in concentration except Alcohol (Maximum antiseptic activity at 70 % concentration) For blood spills:
<1o ml: manual cleaning with absorbent paper then, 1:100 dilution 5.25-6.15% sodium hypochlorite >10 ml: 1:10 dilution first, then manual cleaning, then 1: 100 dilution

Surgical Principles: Halsteds Principles of surgery

Gentle handling of tissue Meticulous haemostasis Preservation of blood supply Strict aseptic technique Minimum tension on tissues Accurate tissue apposition Obliteration of deadspace

Skin Grafts: Knife used: Humbys knife 1. Full thickness Full thickness skin grafts (FTSGs) consist of the entire epidermis and dermis 2. Split thickness Split thickness skin grafts (STSGs) consist of the epidermis and varying degrees of dermis. They can be described as thin, intermediate, or thick

Split thickness Thin Intermediate Thick Full thickness

0.15-0.3 mm 0.3-0.45 mm 0.45-0.6 mm >0.6 mm

Hemostasis: TYPES:

1) Mechanical: Pressure, sutures, staples, ligating clips, gauzes, sponges 2) Thermal: Electrocautery, laser 3) Chemical: a) Pharmacological- epinephrine, Vit K, Protamine sulphate, Desmopressin, Aminicaproic Acid, Tranexamic Acid, Ethamsylate b) Topical- Collagen, cellulose, gelatins, thrombins c) Topical sealants, adhesives- Fibrin sealants, synthetic glues-cyanoacrylates,

Passive: collagen, cellulose, gelatin Active: Thrombin Effectiveness: Microfibrillar collagen > Collagen sponge > Gelatin sponge > oxidized regenerative cellulose

Biopsy Techniques: Types:

Needle biopsy. Most biopsies are needle biopsies, meaning a needle is used to access the suspicious tissue. CT-guided biopsy. A person rests in a CT-scanner; the scanner's images help doctors determine the exact position of the needle in the targeted tissue. Ultrasound-guided biopsy. An ultrasound scanner helps a doctor direct the needle into the lesion. Bone biopsy. A bone biopsy is used to look for cancer of the bones. This may be performed via the CT scan technique or by a surgeon. Bone marrow biopsy. A large needle is used to enter the pelvis bone to collect bone marrow. This detects blood diseases such as leukemia or lymphoma. Aspiration biopsy. A needle withdraws material out of a mass. This simple procedure is also called fineneedle aspiration. Mostly for inaccessible areas. Skin biopsy. A punch biopsy is the main biopsy method. It uses a circular blade to get a cylindrical sample of skin tissue. Surgical biopsy. Either open or laparoscopic surgery may be necessary to obtain a biopsy of hard-toreach tissue. Either a piece of tissue or the whole lump of tissue may be removed. Excisional: for small lesions, whole of the pathological tissue alongwith normal tissue margin is removed. For oral pathologies <1cm, for face and neck <2cm, for other areas <3cm Incisional: For larger pathologies, only a wedge of tissue is removed. FNAB/FNAC : 21/ 22 Gauge needle with aspirator CNB: 14 Gauge needle To preserve tissue: 10% formalin

Incisions: 1. Submandibular incision: Placed 1.5-2 cm below lower border of mandible, approach to mandibular angle, ramus, body 2. Risdons Incision: It is a modification of submandibular incision. Here the submandibular incision is extended posteriorly and curved in best cosmetic confirmity with angle of mandible later being the posterior terminus of incision. 3. Retromandibular/ Hinds incision: It is considered for approaching subcondylar fractures. This incision begins approximately I cm below the lobe of ear and I cm posterior to ramus of mandible. 4. Pre-auricular incision with its variations: This gives the easiest approach to mandibular condyle, although if both condyles need to be exposed for extensive condylar ankylosis, the bicoronal flap may be worthwhile. The pre-auricular incision is sited just anterior to pinna or alternatively around the tragus and at the junction of the ear and the scalp superiorly. It is then directed obliquely forwards and upwards at an angle of 45 5. Al Kayat and Bramley (1979) modification - This modification is used for a wider exposure. They recommended a question mark shaped skin incision which avoids main vessels and nerves. 6. Face lift incision: It comprises a pre-auricular component together with and in continuity with the postauricular component much of which may be in the hair line. 7. Gille's incision: It is also known as temporal fossa approach. The Gillies technique describes a
temporal incision (2 cm in length), made 2.5 cm superior and anterior to the helix, 45 degree to the zygomatic arch, within the hairline. Wards Incision: Intraoral L shaped incision for impacted third molar removal.

8.

LASERS Classification: Soft tissue Laser: Argon, CO2, Nd:Yag, Diode Hard Tissue Laser: Er: Yag

CO2 and Er-YAG-lasers are mainly absorbed by water, resulting in a minimal penetration depth and fast heating, with effective removal of soft and hard tissue. CO2 lasers are mainly used as laser scalpels for the excision of tumors from soft tissues .In a defocused mode, CO2-lasers are used for superficial tissue vaporization, to treat precancerous lesions in the oral cavity . The Er-YAG laser seems to be a highly efficient tool for cutting both soft and hard tissues with minimal damage to the surrounding tissue. However, there are mainly experimental reports on that topic. Nd:YAG lasers emit light at a wavelength range of 1064 nm, which is in-between the absorption maxima of water and blood. The penetration depth is therefore deeper than that of CO2- or Er:YAG lasers and may reach 4 mm, with the possibility of a larger zone of damage to the surrounding tissue. However, due to a higher potency of coagulation, Nd-YAG-lasers are recommended for tissue resection in cases of hemorrhage. Nd:YAG lasers are used for the excision of cancer in a focused mode as well as for the removal of precancerous lesions in a defocused mode. Additionally, they are used solely for coagulation in combination with other lasers or with scalpel excisions. KTP lasers (potassium titanyl phosphate laser) provide light at a wavelength of 532 nm, which is near the absorption maximum of hemoglobin. Hence, KTP-lasers are highly effective hemostatic tools, penetrating the intercellular and intracellular water with minimal absorption or scattering. They are often used for

coagulation, but their effectiveness in the treatment of oral precancerous growth and cancer was demonstrated in several clinical trials, especially when used on the highly vascularized tissue of the tongue

Other laser may be used for special purposes as well. However, the CO2-laser is currently the most widely used . Carbon dioxide laser 10.6 m, (9.4 m)

Nd:YAG laser

1.064 m, (1.32 m)

Er:YAG laser
Argon: blue Kryton : green

2.94 m 0.488 0.528