InIection control

Dental patients and DHCP can be exposed to pathogenic

microorganisms including cytomegalovirus (CMV), HBV, HCV,
herpes simplex virus types 1 and 2, HIV, Mycobacterium
tuberculosis, staphylococci, streptococci, and other viruses and
bacteria that colonize or inIect the oral cavity and respiratory tract.

These organisms can be transmitted in dental settings through

1) direct contact with blood, oral Iluids, or other patient materials;
2) indirect contact with contaminated objects (e.g., instruments,
equipment, or environmental surIaces);
3) contact oI conjunctival, nasal, or oral mucosa with droplets (e.g.,
spatter) containing microorganisms generated Irom an inIected person
and propelled a short distance (e.g., by coughing, sneezing, or
talking); and
4) inhalation oI airborne microorganisms that can remain suspended
in the air Ior long periods .

EIIective inIection-control strategies prevent disease transmission
by interrupting one or more links in these routes.

CDC recommendations regarding inIection control Ior dentistry
Iocused primarily on the risk oI transmission oI bloodborne pathogens
among DHCP and patients and use oI universal precautions to reduce
that risk.

Universal precautions were based on the concept that all blood and
body Iluids that might be contaminated with blood should be treated
as inIectious because patients with blood borne inIections can be
asymptomatic or unaware they are inIected.

Universal precautions apply to contact with

1) blood;
2) all body Iluids, secretions, and excretions (except sweat),
regardless oI whether they contain blood;
3) non intact skin; and
4) mucous membranes.

Selected Definitions

Antiseptic: A germicide used on skin or living tissue Ior the purpose
oI inhibiting or destroying microorganisms (e.g., alcohols,
chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol
|PCMX|, quaternary ammonium compounds, and triclosan).

Bioburden: Microbiological load (i.e., number oI viable organisms in
or on an object or surIace) or organic material on a surIace or object
beIore decontamination, or sterilization. Also known as bioload or
microbial load.

Decontamination: Use oI physical or chemical means to remove,
inactivate, or destroy pathogens on a surIace or item so that they are
no longer capable oI transmitting inIectious particles and the surIace
or item is rendered saIe Ior handling, use, or disposal.

Dental treatment water: Nonsterile water used during dental
treatment, including irrigation oI nonsurgical operative sites and
cooling oI high-speed rotary and ultrasonic instruments.

DisinIectant: A chemical agent used on inanimate objects(e.g., Iloors,
walls, or sinks) to destroy virtually all recognized pathogenic
microorganisms, but not necessarily all microbial Iorms (e.g.,
bacterial endospores). The U.S. Environmental Protection Agency
(EPA) groups disinIectants on the basis oI whether the product label
claims limited, general, or hospital disinIectant capabilities.

DisinIection: Destruction oI pathogenic and other kinds oI
microorganisms by physical or chemical means. DisinIection is less
lethal than sterilization, because it destroys the majority oI recognized
pathogenic microorganisms, but not necessarily all microbial Iorms
(e.g., bacterial spores). DisinIection does not ensure the degree oI
saIety associated with sterilization processes.

Droplet nuclei: Particles 5 m in diameter Iormed by dehydration oI
airborne droplets containing microorganisms that can remain
suspended in the air Ior long periods oI time.

Droplets: Small particles oI moisture (e.g., spatter) generated when a
person coughs or sneezes, or when water is converted to a Iine mist
by an aerator or shower head. These particles, intermediate in size
between drops and droplet nuclei, can contain inIectious
microorganisms and tend to quickly settle Irom the air such that risk
oI disease transmission is usually limited to persons in close
proximity to the droplet source.

Germicide: An agent that destroys microorganisms, especially
pathogenic organisms. Terms with the same suIIix (e.g., virucide,
Iungicide, bactericide, tuberculocide, and sporicide) indicate agents
that destroy the speciIic microorganism identiIied by the preIix.
Germicides can be used to inactivate microorganisms in or on living
tissue (i.e., antiseptics) or on environmental surIaces (i.e.,
disinIectants).

High-level disinIection: DisinIection process that inactivates
vegetative bacteria, mycobacteria, Iungi, and viruses but not
necessarily high numbers oI bacterial spores. FDA Iurther deIines a
high-level disinIectant as a sterilant used Ior a shorter contact time.

Hospital disinIectant: Germicide registered by EPA Ior use on
inanimate objects in hospitals, clinics, dental oIIices, and other
medical-related Iacilities. EIIicacy is demonstrated against Salmonella
choleraesuis, Staphylococcus aureus, and Pseudomonas aeruginosa.

Immunization: Process by which a person becomes immune, or
protected against a disease. Vaccination is deIined as the process oI
administering a killed or weakened inIectious organism or a toxoid;
however, vaccination does not always result in immunity.
Intermediate-level disinIection: DisinIection process that inactivates
vegetative bacteria, the majority oI Iungi, mycobacteria, and the
majority oI viruses (particularly enveloped viruses) but not bacterial
spores.

Intermediate-level disinIectant: Liquid chemical germicide registered
with EPA as a hospital disinIectant and with a label claim oI potency
as tuberculocidal.

Low-level disinIection: Process that inactivates the majority oI
vegetative bacteria, certain Iungi, and certain viruses, but cannot be
relied on to inactivate resistant microorganisms (e.g., mycobacteria or
bacterial spores).

Low-level disinIectant: Liquid chemical germicide registered with
EPA as a hospital disinIectant. OSHA requires low-level hospital
disinIectants also to have a label claim Ior potency against HIV and
HBV iI used Ior disinIecting clinical contact surIaces.

Occupational exposure: Reasonably anticipated skin, eye, mucous
membrane, or parenteral contact with blood or OPIM that can result
Irom the perIormance oI an employee`s duties.

OPIM: Other potentially inIectious materials. OPIM is an OSHA term
that reIers to 1) body Iluids including semen, vaginal secretions,
cerebrospinal Iluid, synovial Iluid, pleural Iluid, pericardial Iluid,
peritoneal Iluid, amniotic Iluid, saliva in dental procedures; any body
Iluid visibly contaminated with blood; and all body Iluids in situations
where diIIerentiating between body Iluids is diIIicult or impossible; 2)
any unIixed tissue or organ (other than intact skin) Irom a human
(living or dead); and 3) HIV-containing cell or tissue cultures, organ
cultures; HIV- or HBV-containing culture medium or other solutions;
and blood, organs, or other tissues Irom experimental animals inIected
with HIV or HBV.

Sterile: Free Irom all living microorganisms; usually described as a
probability (e.g., the probability oI a surviving microorganism being 1
in 1 million).

Sterilization: Use oI a physical or chemical procedure to destroy all
microorganisms including substantial numbers oI resistant bacterial
spores.

SurIactants: SurIace-active agents that reduce surIace tension and
help cleaning by loosening, emulsiIying, and holding soil in
suspension, to be more readily rinsed away.

Ultrasonic cleaner: Device that removes debris by a process called
cavitation, in which waves oI acoustic energy are propagated in
aqueous solutions to disrupt the bonds that hold particulate matter to
surIaces.

Vaccine: Product that induces immunity, thereIore protecting the
body Irom the disease. Vaccines are administered through needle
injections, by mouth, and by aerosol.










nfection Control in the Clinical Area
This can be subdivided into
Personal protection equipment.(PPE)
Environmental surIace cleaning & disinIection.
Instrument sterilization.

!ersonal !rotection Equipment (!!E
The single most important inIection control measures to
minimize direct blood / saliva contact to prevent disease
transmission to the patients &dental care providers .in
general they include
Protective clothing.
Gloves
Masks.
Protective eye wear.
It is mandatory Ior category 1 and 2, the person must wear
PPE when perIorming procedures. When contact with body
Iluids or with mucous membranes or when touching items or
surIaces that may be contaminated with these Iluids.

Category I -~ person routinely perIorm tasks that involve
exposure to blood or other potentially inIectious materials.
Category II -~ are person who an occasion may perIorm
tasks that involve exposure to blood or other potentiall y
inIectious material

!rotective clothing
Primary Iunction oI the protective clothing is to protect the
worker Irom exposure to contaminated material.
They include smokes, slacks, split spirits, lab coats &
surgical scrubs.
Protective clothing is to be worn based on the degree oI
anticipated exposure.

Masks
Worn over the nose & the mouth to protect the wearers Irom
inhaling the possible inIections, organisms spread by the
aerosol spray oI the hand piece, air water syringe or by
accidental splashes.

!rotective eye wear
Its purpose is to protect the eye against the damage
resulting due to the aerolized pathogens especially
herpes.
It also prevents splattered solution or caustic chemicals
Irom injuring the eyes. Such damage may be irreparable
& lead to permanent visual impairment or blindness.



%ypes:-


Gloves
They are to be worn by the dentist, dentist assistant and
the hygienist during all patient treatment , iI there is a
possibilit y oI contact with patient blood , saliva or
mucous membrane .
All gloves used in patient care must be discarded aIter
use.
As washing gloves may cause 'wreaking 'which is the
penetration oI liquids through undetected holes in the
gloves.
Deterioration oI gloves may also be caused by
disinIecting agents, oils, oil based lotions and the heat
oI sterilization.

There are three t ypes oI gloves used in healthcare Iacilities:
surgical, examination and utility or heavy-dut y household
gloves:
W Surgical gloves should be used when perIorming
invasive medical or surgical procedures.
W Examination gloves provide protection to healthcare
workers when perIorming many oI their routine duties.
W Utilit y or heavy-dut y household gloves should be worn
Ior processing instruments, equipment and other items;
Ior handling and disposing oI contaminated waste; and
when cleaning contaminated surIaces.

Sterile or High-Level DisinIected Surgical gloves
W Used Ior all procedures involving contact with tissue
deep under the skin
W Gloves are sized to Iit, permitting greater movement
during surgical procedures.
W Expensive; not to be used Ior tasks where other t ypes oI
gloves can be worn.


Examination gloves
W Used Ior contact with mucous membranes and non-
intact skin
W Exam gloves are one quarter to one third the cost oI
surgical gloves and are easil y available.
W II not available, latex surgical gloves may be washed
and steamed Ior reuse in patient care tasks

Utilit y Or Heavy Dut y Household Gloves
W Used when handling used instruments and equipment
that may have come in contact with blood or body
Iluids and Ior handling medical waste and linens.
W Inexpensive; can be rewashed and reused many times.
The thick rubber surIace helps to protect cleaning
personnel and waste handlers.

Surgical Hand Scrub
Proper hand scrubbing and the wearing oI sterile gloves and
a sterile gown provide the patient with the best possible
barrier against pathogenic bacteria in the environment and
against bacteria Irom the surgical team.
The purpose oI the surgical hand scrub is to reduce
resident and transient skin Ilora (bacteria) to a minimum.
Resident bacteria are oIten the result oI organisms present in
the hospital environment. Because these bacteria are Iirmly
attached to the skin, they are diIIicult to remove. However,
their growth is inhibited by the antiseptic action oI the scrub
detergent used.
Transient bacteria are usually acquired by direct contact and
are loosel y attached to the skin. These are easily removed by
the Iriction created by the scrubbing procedure.

The Iollowing steps comprise the generall y accepted
method Ior the surgical hand scrub.
W BeIore beginning the hand scrub, don a surgical cap or
hood that covers all hair, both head and Iace, and a
disposable mask covering your nose and mouth.
W Using approximatel y 6 ml oI antiseptic detergent
and running water, lather your hands and arms to 2
inches above the elbow. Leave detergent on your arms
and do not rinse.
W Under running water, clean your Iingernails and
cuticles, using a nail cleaner.
W Starting with your Iingertips, rinse each hand and
arm by passing them through the running water. Always
keep your hands above the level oI your elbows.
W From a sterile container, take a sterile brush and
dispense approximately 6 ml oI antiseptic detergent
onto the brush and begin scrubbing your hands and
arms.
W Begin with the Iingertips. Bring your thumb and
Iingertips together and, using the brush, scrub across
the Iingertips using 30 strokes.
W Now scrub all Iour surIace planes oI the thumb and all
surIaces oI each Iinger, including the webbed space
between the Iingers, using 20strokes Ior each surIace
area.
W Scrub the palm and back oI the hand in a circular
motion, using 20 strokes each.
W Visuall y divide your Iorearm into two parts, lower and
upper. Scrub all surIaces oI each division 20 strokes
each, beginning at the wrist and progressing to the
elbow.
W Scrub the elbow in a circular motion using 20strokes.
W Scrub in a circular motion all surIaces to approximately
2 inches above the elbow.
W Do not rinse this arm when you have Iinished
scrubbing. Rinse only the brush
W Pass the rinsed brush to the scrubbed hand and begin
scrubbing your other hand and arm, using the same
procedure outlined above.
W Drop the brush into the sink when you are Iinished
W Rinse both hands and arms, keeping your hands above
the level oI your elbows, and allow water to drain oII
the elbows.
W When rinsing, do not touch anything with your
scrubbed hands and arms.
W The total scrub procedure must include all
anatomical surIaces Irom the Iingertips to
approximatel y 2 inches above the elbow.

Glove powder
This acts as an additional barrier against micro-organisms,
since it Iills the minute crevices in the hands.
It is important to note that gloves are meant to supplement,
and not replace the hygienic practice oI proper hand
washing.


Environmental Surfaces Cleaning & Disinfection:
1.In general surIace sepsis can be achieved by 2 methods.
By cleaning and disinIecting the contaminated surIace.
2.Preventing the surIace Iorm becoming contaminated in
the working place by the use oI surIace covers.


The Iollowing are some oI the criteria Ior eIIective chemical
disinIection:
W Concentration oI the chemical
W Contact time
W ShelI liIe
W The degree oI microbial kill or deactivation required.
W The composition and texture oI the item being treated.
W The technical requirement and ease oI use oI the available
agents.

The EPA classiIies disinIectants as high,
intermediate, or low level, based on the eIIectiveness and
contact time oI the solution and the biocidal activit y oI an
agent against bacterial spores, mycobacterium tuberculosis,
lipid and non lipid viruses, and vegetative bacteria.










!rocess Result Method examples
GENERAL CLEANNG !ROCEDURES N DEN%AL
CLNC

Before the start of a treatment session
W Clean with detergent
1.All items and equipment including
W Chair base, head rest, stand, Side arm and
tray holder, Air rotor couplings, Light,
Suction bottles
2.House keeping surIaces like
W Drawers, counter top, wash basin, window sill
and blinds, Iloor
3.Line the waste bucket with a plastic bag
4.Change hand towels or replenish tissues
5.Arrange sterile patient care items
6.All treating staII to wear glasses, gloves, mask and
apron

In between patients
W Wipe tray holder and clean spittoon
W Used items to be sterilized
W Change evacuation tips, handpiece, ultrasonic insert,
light cure tip, iI used
W Used items to be disposed careIully into waste buckets
W Prepare items Ior next patient
W Change tumbler, bib
W Adjust chair and light position
W Reglove

During procedures
W Following surIaces to be handled wearing gloves:
W Cheatle Iorceps, light handle, light switch,
chair control buttons, spittoon and tumbler
control switches, light cure gun, patient
records, material bottles, telephone, trolley
handle, X-ray tubes and switches
W Fine instruments and materials like reamers, Iiles, G.P.
points and cotton balls should be retrieved with a
separate sterile tweezer. Disposable syringes Ior local
anaesthetic should not be reIilled Ior repeat injections.

At the end of the day and whenever required
W Clean instrument tray and spittoon send waste Ior
disposal
W Clean and replace waste bucket
W Run airotor lines Ior 2-3 minutes to Ilush the hoses
W Instruments and trays should be washed, rinsed, dried
and sterilized


!atient examination
W Dental examination should be done with mouth mirror
and probe
W Used instruments should be kept in a separate tray Ior
removal


nfection Control Regulations
OSHA
W This standard indicates that it is the employers`
responsibilit y to protect employees Irom exposure to
blood and OPIM in the work place, and other proper
care must be given iI such exposure does occur.
W It applies to employers in any type oI Iacility where
employees have a potential Ior exposure to body Iluids
W Compliance is monitored through complaints, or
investigation oI the Iacilit y providers in the absence oI
complaint.
W Non-compliance can result in a Iine.

Cuidelines
W Review the standard
W Prepare a written exposure control plan
W Train the employees
W Provide employees everything needed to comply with the
standard
W OIIer hepatitis B vaccination series
W Provide, maintain, dispose oI or clean and ensure use oI
personal protective equipment and/or engineering controls
W Establish appropriate work practices and decontamination
procedures
W Establish post exposure medical evaluation and Iollow up
W Provide appropriate biohazard communication
W Maintain appropriate records

Four Iactors are associated with increased risk oI
occupationally acquired HIV inIection:
W Deep injury
W Visible blood on the device which caused the injury
W Injury with a needle which had been placed in a source
patient`s blood vessel
W Terminal HIV- related illness in the source patient.


In the event oI an injury with a sharp object such as a needle
or scalpel that has been used on a patient or in the event oI a
mucous membrane surIace contaminated with blood or
secretions Irom a patient, the Iollowing steps should be
Iollowed:
W Allow blood to Ilow Ireel y Irom wound iI bleeding.
W Wash exposed area thoroughly with soap and water but
without scrubbing.
W Rinse eye or mouth with plenty oI water iI contaminated.
W Report the injury immediatel y to a senior member oI staII,
supervisor or the post exposure prophylaxis designated
oIIicer oI the unit.
W Take antiretroviral drugs recommended Ior post-exposure
prophylaxis immediatel y- this should be started within one
hour iI possible and at the latest within 72 hours oI the
exposure. Persons presenting aIter 72 hours should also be
considered Ior post-exposure prophylaxis.
W Ascertain the HIV status oI the patient and the exposed
health worker aIter providing appropriate pretest
counseling- the standard rapid HIV antibody test that are
currently used in the voluntary counseling and testing
programme should be used and the result oI the tests
obtained as quickly as possible.
W It has been shown that immediate administration oI
antiretroviral drugs may prevent inIection Irom occurring.
Studies in health care workers who have had needle stick
exposures have shown that post. exposure treatment with
antiretroviral drugs can reduce the risk by 79
W There are three t ypes oI exposure in health care settings
associated with signiIicant risk.
These are:
W Percutaneous injury (Irom needles, instruments, bone
Iragments, signiIicant bites which break the skin, and
so on);
W Exposure oI broken skin (abrasions, cuts, eczema and
so on)
W Exposure oI mucous membranes including the eye.


The Risk Is Assessed As Follows.
W Negligible Risk: for example intact skin visibly
contaminated with blood or body Iluids.
Management. reassurance and discharge

W Low Risk: solid needle, superficial exposure on intact skin
Small volume (drops oI blood) on mucous membrane or non-
intact skin exposures. Source is asymptomatic or viral load
1500copies/ml
Management. counsel patient about risk of HIJ, HBV and
HCV transmission. Discuss risk oI HIV post-exposure
prophylaxis- iI risk outweighs potential beneIits

W Moderate Risk: for example skin-penetrating needle
contaminated with blood or body Iluid; wound causing
bleeding and produced by sharp instrument visibly
contaminated with blood.
Management. counsel patient about risk of HIJ, HBV and
HCV transmission. Discuss risk oI HIV post-exposure
prophylaxis. Accelerated HBV immunization or booster iI
already immunized. Give 2-drug combination iI required.

W High Risk: large bore needle, deep injury, and visible
blood on device, needle in patient.s artery/vein. Source
known to be HIV, HBV or HCV inIected. Large volume
(major blood splash on mucous membrane or non-intact skin
exposures) Source patient is symptomatic, acute
seroconversion, high viral load.
Management. counsel patient about risk of HIJ, HBV and
HCV transmission. Discuss risk oI HIV post-exposure
prophylaxis. Accelerated HBV immunization or booster iI
already immunized. Consider HBV Immunoglobulin iI
source is a highl y inIectious HBV carrier and patient is
susceptible. PEP deIinitely indicated. Gi ve 3-drug
combination therapy. This regimen needs to be modiIied iI
index case is likel y to harbour drug resistant virus




H' !ost-Exposure Antiretroviral Drug %herapy
PEP should be commenced within 1-2 hours oI exposure and
should last one month Ior it to be eIIective.
At least 6 months should elapse aIter cessation oI PEP
beIore a negative antibody test is used to reassure the
individual that inIection has not occurred.
Following any occupational exposure to HIV, whether or not
PEP was prescribed, health care worker should attend
occupational health Iollow up Ior 6 months and be prepared
to report symptom oI concern at any time.
Recommended 2-drug combination:
W Zidovudine 300mg twice dail y lamivudine 150mg twice
dail y
W Stavudine 40mg twice daily lamivudine 150mg twice
dail y
W Stavudine 40mg twice dail y didanosine 400mg once daily
Recommended 3-drug combination:
PreIerred combination is a 2-drug combination and EFV
(600mg once dail y) or NelIinavir (NFV) 1250mg bd or
lopinavir/retonavir (LPV/RTV)( 400mg/100mg twice dail y).
The chosen regimen is continued Ior 28 days or until the
result oI HIV test Ior the patient and exposed health worker
is known to be negative.
EIavirenz is not given iI pregnancy is suspected or patient is
in reproductive age group.
&se of Antiretroviral 1herapy Following Exposure to
Potentially Infectious Body Fluids
Depending on the result oI the HIV test, the Iollowing action
should be taken:
II the source patient is HIV negative:
W No Iurther post-exposure prophylaxis is required Ior the
exposed health worker.
II the exposed health worker is HIV positive:
W No Iurther post-exposure prophylaxis is necessary.
W The health worker should be reIerred Ior Iurther counselling
and management on a long term basis.
W II the health worker is HIV negative and the source patient
is HIV positive:
W Continue antiretroviral Ior a period oI Iour weeks;
W Repeat health worker.s HIV test at 3 months and 6 months
aIter the initial test.
W Should the health worker seroconvert during this period then
provide adequate care and counseling and reIer Ior expert
opinion and long term management
W II it is not possible to determine the HIV status oI the source
patient:
W Assume that the source patient is positive and proceed
according to guideline above
!rophylaxis against HB' and HC'
W Prophylaxis against hepatitis B is recommended Ior patients
with potential exposure to HBV who have not been
vaccinated against HBV.
W Give hepatitis B immune globulin (HBIG) as a 0.06-mL/kg
intramuscular injection and initiate the vaccination series.
W For patients who received the vaccine series but did not
develop protective antibody (HBV surIace antibody
positive), give HBIG at the time oI the postexposure workup
and repeat in 1 month.
W For patients with immunit y to hepatitis B, no treatment is
indicated.
W For hepatitis C, no recommended prophylactic treatments are
available.
W AIter potential exposure, conduct a baseline HCV antibody
test.
W II the source is known to have HCV inIection, consider
alanine aminotransIerase (ALT) and HCV viral load testing
at 4-6 weeks. HCV antibody testing should be repeated at 4-
6 months.
W II HCV seroconversion occurs (indicated by ALT elevation,
detectable HCV viral load, or conIirmed positive HCV
antibody test), reIer the patient to a hepatologist because
earl y treatment oI HCV may be indicated.

After treatment of ADS or Hepatitis B infected patients
the following precautions and steps should be followed
CON%AMNA%ED SHAR! AR%CLES such as needles
blades etc.,inIectious sharp ) carries with them the highest
risk oI transmission oI blood borne pathogens due to its
ability to penetrate soIt parts & reach vascular tissue
Storage & transport oI these articles should be done in the
puncture resistant container made oI either thick plastic or
metal. These containers should be labeled , colour coded ,
with a bio-hazard label or sticker.

DS!OSAL OF NEEDLES: Immediate disposal oI needles
without recapping into a designated puncture resistant
container is the best option without any manipulation oI the
needle what so ever
FNAL DS!OSAL OF NEEDLE CON%ANERS (W%H
%HE NEEDLES may be done by destruction oI the
container preIerabl y by heat.

BLOOD OR BODY FLUD SOAKED !ACKS, GAUZE
!ECES AND O%HER DS!OSAL EQU!MEN%S

These have a low rate oI transmissibilit y in comparison
to sharps as they cannot penetrate but can transmit the
pathogens through non intact skin.
These should be placed or discarded in moisture resistant
containers made oI Materials like plastic or pol ythene.

ITEMS THAT ARE TO BE REUSED should be
decontaminated beIore processing Ior reuse. DisinIectants
like 1 Sodium hypochlorite or 7 Lysol can be used Ior
the purpose. The article should be leIt soaked in this Ior at
least 30 minutes. CIDEX (2 Gluteraldehyde) is good Ior
delicate instruments like handpiece.

Key Steps in Chemical Disinfection
W Decontaminate instruments and other items that may have
been contaminated with blood and body Iluids, and
thoroughly clean and dry them beIore placing them in the
disinIectant solution.
W Completel y immerse all items in the high-level disinIectant.
W Soak Ior 20 minutes.
W Remove items using high-level disinIected or sterile Iorceps
or gloves.
W Rinse well with boiled and Iiltered (iI necessary) water three
times and air dry.
W Use promptl y or store in a dry, high-level disinIected,
covered container.

Selection of Sterilization Methods and Equipments

Selection oI sterilization method and equipments should be
done according to the oIIice needs. Kinds and size oI
sterilization equipments depends upon the treatment and
instrumentation used in the practice. Choose reliable
sterilization equipment oI proper size and cycle time,
compatible with the needs oI the practice. Any method oI
sterilizing instruments must be reliable, practical and saIe
Ior the instruments. Choosing equipment that is well
established is still the saIest and most reliable approach.
Heat and gas sterilization are the most dependable and
acceptable methods oI sterilization

'AROUS AGEN%S USED N S%ERLZA%ON

!HYSCAL AGEN%S
SUN LIGHT
DRYING
DRY HEAT
MOIST HEAT
FILTRATION
RADIATION
ULTRASONIC AND SONIC VIBRATIONS

CHEMCAL AGEN%S
ALCOHOLS
ALDEHYDES
HALOGENS
PHENOLS
SURFACE ACTIVE AGENTS
METALLIC SALTS
GASES

ACCE!%ED ME%HODS OF S%ERLZA%ON
There are Iour accepted methods oI sterilization.
They are:-
1)Steam Pressure Sterilization Autoclave
2)Chemical Vapour Pressure Sterilization Chemiclave
3)Dry Heat Sterilization
4)Ethylene Oxide Sterilization Each method and its
commercial modiIication has very speciIic requirements
regarding Iine temperature suitable packaging oI
materials and kinds oI items and materials that can be
easily, saIel y and eIIectivel y sterilized, ignoring any oI
these speciIications can damage materials or
instruments or deIeat sterilization.




Methods of sterilization

METHOD TIME TEMPERATURE PRESSURE
MOIST HEAT
STEAM UNDER
PRESSURE(STEAM
AUTOCLAVE)
15-30
Min
250HF
121HC
15PSI
DRY HEAT
OVEN
120
Min
320HF
160HC

UNSATURATED
CHEMICAL
VAPOUR
20
Min
270H F
132HC
20-40 PSI
ETHYLENE
OXIDE GAS
10-16
HR
750HF
25 HC



ME%HODS OF S%ERLZA%ON
!HYSCAL ME%HODS
1 SUNLGH%
Sunlight due to its content oI ultraviolet rays possesses
appreciable bactericidal activit y. It plays an important role
in spontaneous sterility. Its sterilizing power varies
according to the circumstances; like in tropical countries it
has an active germi cidal eIIect due to the combined eIIect oI
ultraviolet rays and heat rays. Bacteria suspended in water
are readily destroyed by exposure to sunlight (in case oI
water in river, tanks and lakes).
2 DRYNG
Moisture is essential Ior the growth oI Bacteria.
Susceptibilit y to drying varies with diIIerent Bacteria and
also on the conditions under which they are exposed to
drying.

This method is unreliable and is onl y oI theoretical
interest. Spores are unaIIected by drying.

3 HEA%

a) DRY HEAT
b) MOIST HEAT
Heat is the most reliable method oI sterilization, and should
be the method oI choice unless contra indicated. Material
damageable by heat can be sterilized at low temperatures Ior
longer periods or by repeated cycles.

DRY HEA% S%ERLZA%ON (DRY CLA'E
This is a less eIIicient process as compared to moist
heat, and bacterial spores are most resistant to it. This
method is used most commonl y to sterilize glassware and
bulky items that can withstand heat, but are susceptible to
rust. Since the success oI sterilization depends not onl y on
attaining a certain temperature, but also on maintaining the
temperature Ior a suIIicient amount oI time, several Iactors
must be considered when using dry heat.


They are:-
1.Warm up time Ior the oven and materials to be
sterilized.
2.Heat conductivity oI the material.
3.Air Ilow throughout the oven and through the object to
be sterilized.
4.Time Ior the sterilized equipment to cool, also must be
considered.

The time necessary Ior dry heat sterilization limits its
practicality. It `s use is limited to the sterilization oI those
items that cannot withstand the corrosive action oI steam or
to situations when direct contact with saturated steam to all
surIaces oI the articles is impractical or unattainable. Some
oI the items are powders, oils, grease, carbon steel
instruments and glass ware.
The killing eIIect oI dry heat is due to:-
1)Protein denaturation
2)Oxidative damage
3)Dehydration
4)Toxic eIIect oI elevated levels oI electrol ytes.

The methods oI sterilization using dry heat are,
A FLAMNG
Inoculating loops or wires, points oI Iorceps &
searing spatulas are held in a Bunsen Ilame till they are red
hot, Ior sterilizing them. Scalpels, needles, mouths oI
culture tubes, glass slide, cover slips, etc., are sterilized in
the microbiology laboratory.
BNCNERA%ON
This is an excellent method Ior rapidl y destroying
materials such as soiled dressing, animal carcasses, bedding
and pathological materials.

A CON'EN%ONAL DRY HEA% O'ENS:
These are merely heated chambers that allow air to circulate
by gravity Ilow (gravit y convection).

To allow heat to pass through i.e. to allow the heated
air to circulate, packs oI instruments must be placed at least
1 cm apart.
The oven is usually heated by electricit y with heating
elements in the wall oI the chamber and it must be Iitted
with a Ian to ensure even distribution oI air and elimination
oI air pockets.

!recautions:
- It should not be over loaded.
- Glassware should be perIectl y dry beIore being placed
in the oven.
- Rubber materials except silicone rubber will not stand
temperature.
- The oven must be allowed to cool slowly Ior about 2
hours beIore the door is open, since the glass ware
may get cracked by sudden or uneven cooling.

SHOR% CYCLE HGH %EM!ERA%URE DRY HEA%
O'ENS
This is a rapid high temperature process that uses a
Iorced draIt oven i. e. a mechanical convection oven that
circulates air with the Ian or a blower. It reduces the total
sterilization time to 6 minutes Ior unwrapped instruments.

They operate at approximately 370H to 375HF To
calibrate a sterilization cycle a pyrometer is attached to a
thermocouple wire. (an external temperature gauge).


AD'AN%AGES OF DRY HEA%:
1.Relative ease oI use.
2.Carbon steel instruments & burs do not rust, corrode or
lose their temper or cutting edges iI they are well dried
beIore processing
3.Rapid cycles are possible at high temperatures.
4.A number oI time-temperature combinations can be
used.

DSAD'AN%AGES OF DRY HEA%
1.Time necessary limits its practicalit y
2.High temperatures may damage more heat sensitive
items such as rubber or plastic items
3.Sterilization cycles are prolonged at lower temperatures
4.Cycles are not automaticall y timed on some models
5.Inaccurate calibration, lack oI attention to proper
setting and adding instruments without restarting the
timings are common sources oI errors.
6.Heavy loads oI instruments, crowding oI packs and
heavy wrapping can easily deIeat sterilization
%ME - %EM!ERA%URE RELA%ONSH!:

TEMPERATURE HOLDING PERIOD
~160 c ~120 minutes
~170 c ~ 60 minutes
~180 c ~ 30 minutes

GLASS BEAD S%ERLZA%ON
It is normally used to reduce contamination during
treatment as Iiles are autoclaved between patients. It is a
t ype oI dry heat sterilization. It sterilizes in the temperature
range oI 218 - 248Hc with time standards can be veriIied
onl y by physical and biological monitoring heat. It is an
eIIective method, provided the instrument to be sterilized is
held in the heat conducting material Ior a minimum oI 10
seconds.

Disadvantage:-
It is relativel y easy to carry beads into the root canal
and cause an obstruction.
Handle portion is not sterilized.

HO% SAL% S%ERLZER:-
It is compact and eIIicient. It consists essentially oI a
metal cup in which table salt is kept at a temperature
between 218Hc and 246Hc. At this temperature root canal
instruments such as reamers and Iiles may be sterilized in 5
seconds and absorbent points and cotton pellets in 10
seconds.


AD'AN%AGE:
Use oI ordinary table salt which is readily available Ior
replacement instead oI beads and eliminates the risk oI
clogging the canal.

DSAD'AN%AGE:
Handle portion is not sterilized.

MOS% HEA%
'AROUS MODELS OF AU%OCLA'E:
1SM!LE GRA'%Y DS!LACEMEN% MODELS
A Temperature oI 121HC at a pressure oI 15 psi Ior 30
minutes is used.

2AU%O CYCLED HGH !RESSURE 'ACCUM
MODELS
For practical consideration high pressure models are
operated at temperature oI 136HC at a pressure oI 32 psi and
a holding period oI 5 minutes is used.

3FLASH S%ERLZA%ON
A temperature oI 134HC at 29.4 psi pressure is used Ior
3 min normall y in autoclave sterilization to provide margins
oI saIety usually 20-30 minutes are used.

MECHANSM OF NAC%'A%ON BY MOS% HEA%
ON MCROBAL BAC%ERAL S!ORES:
1)Denaturation oI spore enzymes.
2)Impairment oI germination.
3)Damage to cell membrane.
4)Structural damage.
5)Damage to chromosome.
6)Increases sensitivit y to inhibiting agents.

NON - S!ORNG BAC%ERA:
1)Damage to cytoplasmic membrane.
2)Break down oI RNA.
3)Coagulation oI proteins.
4)Damage to bacterial chromosome.

AD'AN%AGES OF AU%OCLA'E:
(Steam !ressure Sterilization
1.It is the most rapid and eIIective method Ior
sterilization oI cloth surgical packs, and towel packs.
(Other methods are not suitable Ior processing cloth
packs).
2.Autoclaves handle trays and paper-bagged instruments.
3.Temperature can be accuratel y controlled.

DSAD'AN%AGES OF AU%OCLA'E
No Iacilit y Ior drying the load aIter sterilization and beIore
taking it out.
Method oI air discharge is ineIIicient and it is diIIicult to
decide when the discharge is complete.
Items sensitive to the elevated temperature cannot be
autoclaved.
Tendency oI moist heat to rust or dull instruments (tend to
rust carbon steel instruments. )

%MES AND %EM!ERA%URES FOR AU%OCLA'E
Temperature Holding Period (In Minutes)
121HC 15
126 HC 10
134 HC 3

CHEMCAL 'A!OUR !RESSURE S%ERLZA%ON
(CHEMCLA'E

Sterilization by chemical vapour pressure is perIormed in a
CHEMCLA'E. This operates at 131HC at 20 lbs pressure
Ior about hour it is similar to steam sterilizer. These
sterilizers must be used with a prescribed chemical.

Newer modes oI Chemiclave appear to handle Aldehyde
vapours well loading cautions are similar to those Ior
autoclaving. Water leIt on instruments loaded into the
chamber can deIeat sterilization.

AD'AN%AGES OF CHEMCLA'NG
Carbon Steel and other corrosion sensitive burs,
instruments and pliers are said to be sterilized without rust
or corrosion.

DSAD'AN%AGES
Items sensitive to elevated temperature will be
damaged.
Towels and heavy cloth wrapping oI surgical
instruments may not be penetrated to provide
sterilization.
Must be lightl y packed.

FL%RA%ON
This is the method used to rid heat labile liquids oI
microorganisms. UseIul Ior antibiotic solutions, and
carbohydrate solutions used in the preparation oI culture
media. We can obtain bacteria Iree Iiltrates oI toxins and
bacteriophages.

Various t ypes oI Iilters in use in microbiology

Earthen Ware Candles - Berkefeld Chamberland
1.Asbestos Disc Filters e.g.: Seitz.
2.Sintered Glass Filters.
3.Membrane Iilters.

MEMBRANE FL%ERS
These are widely used now-a-days. These are made up
oI CELLULOSE ES%ER and are not suitable Ior preparing
sterile solutions.
The range oI pore size in which these are available is
0.05 12 mm, where as the required pore size Ior
sterilization is in the range oI 0. 02 022 mm.

A!!LCA%ONS OF FL%ERS
1.Sterilization oI thermolabile parenteral and
ophthalmic solution.
2.Sterilit y testing oI pharmaceutical products.
3.ClariIication oI Water supplies.
4.Microbiological evaluation oI water purity.
5.Viable counting procedures.
6.Determination oI virus particle size.
7.Air Sterilization.
8.Sera Sterilization.
9.Sterilization oI antibiotics, vaccines, serum.

A practical limitation oI Iiltration is Ilow rate decreases as
viscosit y oI the liquid increases.
DSAD'AN%AGE:-
Virus and Mycoplasma may pass through Iilter. So Iiltered
serum is not saIe Ior clinical use.

7RADA%ON
Two types oI radiations are used Ior sterilization purpose.
1. Non Ionising
2. Ionising

NON - ONSNG RADA%ON`S
1. Ultraviolet
2. InIrared
Ultraviolet and InIrared Radiations are used. These are
electromagnetic rays with wavelengths longer than those oI
visible light and to a large extent are absorbed as heat.

USES:-
InIrared rays are used Ior mass sterilization oI
syringes.
Ultraviolet rays are mainl y used Ior disinIecting enclosed
areas such as entry ways, hospital wards, operation rooms,
virus laboratories, small virus inoculation rooms.

Ultraviolet rays oI wavelengths between 250 and 270 mm
are used. It is absorbed by nucleic acids oI the organism.
Ultraviolet rays damage microbial cells by disrupting
hydrogen bonds and causing thymine diamers to Iorm in the
DNA, which leads to lethal Irame shiIt mutations.

DSAD'AN%AGES OF UL%RA'OLE% RAYS
1. Poor Penetrating Energy
2. Absorption by glass and water.

ONSNG RADA%ONS
They are X rays, Gamma Rays and Cosmic Rays. They
have very high penetrating power. There is no appreciable
increase in temperature. So this method is reIerred to as
COLD S%ERLZA%ON
They act by Iormation oI FREE RADICALS which
chemically react with proteins and nucleic acid to cause cell
death.



Uses:-
Large commercial plants use Gamma rays Ior sterilizing
most plastics, syringes, swabs, catheters, culture plates etc.
For single use disposable medical items

DSAD'AN%AGE
They are potentially dangerous to human cells.

8MCROWA'ES
Used in the labs Ior rapid sterilization oI media that has
been stored Ior a long period oI time. Action is by the result
oI heat produced by the radiation rather than a direct eIIect
oI microwaves.

UL%RASONC AND SONC 'BRA%ONS:
Micro-organisms vary to their sensitivit y and this method is
oI no practical value in sterilization and disinIection.

CHEMCAL AGEN%S
A large number oI varieties oI chemical agents are used as
antiseptics and DisinIectants. They are:

1.ALCOHOL: Most commonly used are ETHYL
ALCOHOL and ISOPROPYL ALCOHOL. They act by
denaturing bacterial proteins. They are mainl y used as
skin Antiseptics. They have no action on spores and
viruses. To be eIIective, the concentration used is 60 -
70 oI water.

2. ALDEHYDES: Formaldehyde and Gluteraldehyde are
used
a) Formaldehyde It is eIIective against the amino group in
the protein molecule. In the aqueous solutions, it is
markedl y bactericidal, sporicidal, and possesses lethal eIIect
on viruses.

Uses:-
To preserve anatomical specimens.
a.To sterilize heat sensitive catheters and clean metal
instruments. Percentage used is 2-5.
b.Gluteraldehyde: Its action is similar to Iormaldehyde. It
is especially eIIective against tubercle bacilli, Iungi and
virus. It is used mainl y to treat corrugated rubber
anesthetics tubes, Iace masks, plastic endotracheal
tubes, metal instruments, respirators.

3.DYES :
There are two t ypes oI Dyes
I. Aniline Dyes.
II. Acridine Dyes.
Both are bacteriostatic in high dilutions and are used as skin
and wound antiseptics. They are not active against tubercle
bacilli. They act by impairing the DNA COMPLEX oI the
organism and thus kill or destroy the reproductive capacity
oI the cell.
Use: - in lab as selective agents in culture media.

HALOGENS
Mainly used are
- IODINE
-CHLORINEIODINE
It is a skin disinIectant in aqueous solutions and
alcoholic solutions.
O An active bactericidal agent.
O Moderate action against spores.
O Normal percentage used is 5.


CHLORNE
It is used as disinIectant Ior years, mainl y in water supplies,
swimming bath, Food and dairy industries. Most commonly
used as Hypo chlorites. It is markedly
Bactericidal and active against wide spectrum oI viruses.


!HENOLS
Their lethal eIIect is due to their capacity to cause cell
membrane damage, thus releasing cell contents and causes
l ysis. Agents used are,
a)Carbolic acid : It is a powerIul microbicidal substance
b)Lysol cresols: It is active against wide range oI
organisms. Various proprietary preparations oI phenols
are used.
E.g. chlorophenols, chloroxyphenols and their various
combinations are used.
c)Chlorhexidine : ( Hibitane )
It is a relativel y non-toxic skin antiseptic.
Mostly active against gram ve organisms and
Iairl y active against gram ve ones.
It is eIIective in the presence oI pus or blood.
Normal percentage used is 5.

GASES
1. ETHYLENE OXIDE
2. FORMALDEHYDE
3. BETA PROPIOLACTONE (BPL )

7 E%HYLENE OXDE S%ERLZA%ON
It is the gentlest method oI sterilizing complex
instruments and delicate materials.
Ethylene oxide is a colourless liquid with a boiling
point oI 10.7HC. At normal temperature and pressure it is a
very penetrating gas with a sweet ethereal smell. It is highl y
inIlammable and in concentrations in air greater than 3, it
is highly explosive.

Its explosive tendency is eliminated by mixing it with inert
gases such as carbon dioxide, Nitrogen, Freon.

It is eIIective against all t ypes oI microorganisms
including viruses and spores. It diIIuses through many types
oI porous materials and readil y penetrates some plastics

Porous and plastic materials absorb and require aeration
time oI 24 hours or more beIore it is saIe Ior them to remain
in contact with skin or tissues.

Automatic devices sterilize items in several hours (3
hrs) and operate at elevated Temperatures well below 100 HC
Less expensive equipments operate over night (around
14 hrs) to produce Sterilization at room temperature.




Mechanism of Action
Action oI ethylene oxide is due to its power oI alkylating the
amino, carboxyl, and sulphydryl groups oI the protein
molecule.

Hazards of using Ethylene oxide:
It includes potential hazards oI Ethylene oxide
including mutagenicit y and carcinogenicity to man.
Uses:
a)It is used speciall y Ior sterilizing heart-lung machines.
b)Respirators
c)Sutures
d)Dental Equipments
e)Books, Clothing
I)Glass, metal and paper surIaces
g)Plastics, soil, some IoodstuIIs & tobacco

Advantages:
a.High penetrating capacity(penetrates readily through
some plastics)
b.Suitable Ior sterilizing heart-lung machines.
c. EIIective against all types oI microorganisms including
viruses & spores.
d.Materials sensitivit y to heat or moisture can be
sterilized.

Disadvantages:
a)Mutagenecity
b)Carcinogenicit y.
c)Equipments exposed to ethylene oxide need aeration oI
at least 8- 12 hrs (at 50Hc) due to its toxicit y.
d)Increased holding time.
e)It is an irritant.
I)Need Ior special equipment.
g)It is unsuitable Ior Iumigating rooms because iI its
explosive tendency.
h)It is rarel y practical Ior its dental use.

SURFACE AC%'E AGEN%S
These are substances which alter energy relationships at
interIaces producing a reduction oI surIace or interIacial
tension. They are widely used as wetting agents, detergents
and emulsiIiers.

CLASSFCA%ON
1.ANIONIC e.g., Common Soap
2.CATIONIC are the most important surIace active
antibacterial agents. They act by denaturation oI proteins.
The commonly used are Cetyl Trimethyl Ammonium
Bromide ( cetavlon or cetrimide)
- Benzalkonium
3. NONIONIC
4. AMPHOTERIC
- They are active against gram ve & gram ve
organisms.
- They are not in use.
MCROWA'E O'EN
It has major limitations Ior sterilizing metal item
without damaging the machine and researching all sides oI
the instruments.
Research to overcome such limitations are ongoing in
industry.

A rational approach to sterilization & disinIection
W Critical instruments that penetrate the mucosa must
be sterilized. Eg. Extraction Iorceps, scalpel blades,
bone chisels, periodontal scalers, and surgical burs
W Semi-critical instruments that touch the mucosa
should be sterilized. Eg. Amalgam condensers, and
air/water syringes
W Non-critical surIaces touched during treatment should
be disinIected.


%Y!ES OF NS%RUMEN%S AND S%ERLZA%ON
ME%HODS

Recommended Sterilization Procedures For Commonly Used
Articles
Articles Sterilized By Using Moist Heat As The First Choice
OI Sterilization.


Extraction Iorceps
Periosteal Elevators
Dental Elevators
Chisel / Osteotome
Mallet
Bone Ronguers
Bone Files
Artery Iorceps
Thumb Iorceps
Needles holder
Scissors
Surgical Box
Surgical Hand Piece
Air rotor hand piece
Rubber tube suction
Corrugated rubber drain
Bone Currette
Periodontal Currete
Tweezers
Erich`s arch bar
Stainless steel wires




Mouth gag
Acrylic Splint
Impression tray
Mouth mirror
Probe
Wire Cutter
Ultrasonic tip
3 way syringe
S.S Tumblers
Glass slab
Dappen Dish
Amalgam Carrier
Needles
Gauze
Gloves
Suction tip
B.P. Handle
Files/Reamers
Matrix Band Retainer
Filling instruments
Plastics cement spatula
Light cure tip
Cheek / lip retractors
Saliva ejector


Culture media
Lab coats
Slides



AR%CLES S%ERLZED BY USNG HO% AR O'EN
AS %HE FRS% CHOCE OF S%ERLZA%ON.
Glass Wave
Beekers
Flasks
Test .
Tubes
Glycerine
Oils
Papers

AR%CLES S%ERLZED BY USNG E%HYLENE
OXDE AS %HE FRS% CHOCE OF S%ERLZA%ON
Air rotor cord
Micro motor cord
Cautery tip
Ultrasonic cord
Suture
Disposable instruments
Blades, Scalpels
Scissors
Plastics
Bronchoscope
Crystoscope

FOLLOWNG %EMS MAY BE S%ERLZED BY
FL%ERA%ON
Antibiotics
Serum
Vaccines

Commonly used STAINLESS STEEL INSTRUMENTS
AND MIRRORS used Ior periodontal, restorative and
endodontic procedures are readil y processed by
autoclave or chemical vapour pressure sterilization or
any accepted method oI sterilization.
CARBON STEEL INSTRUMENTS AND BURS, iI dried
well beIore use sterilizing are best sterilized by dry heat
and chemical vapour Pressure sterilizers with less risk.
BOTH HIGH AND LOW SPEED HAND PIECES are
best autoclaved at the present time.
METAL IMPRESSION trays can be sterilized by any
method but dry heat above 345HC may remove the
soldered handles.
TOWELS AND TOWEL PACKS oI instruments needed
Ior surgery are best sterilized by autoclaving.
BONE GRAFTS are pre-sterilized by using Gamma
rays by the manuIacturer.
Secondary sterilization:- done by a chair side
sterilization technique using glass bead or salt sterilizer.

Sterilization Monitoring

STERILIZATION MONITORING HAS FOUR COMPONENTS
1. Sterilization indicator on the bag and date oI
sterilit y.
2. Daily process indicator strips
3. Weekly biological spore tests
4. Documentation note book

Monitoring oI sterilization procedures should include a
combination oI process parameters, including mechanical,
chemical, and biological.
These parameters evaluate both the sterilizing conditions
and the procedure`s eIIectiveness.
Mechanical techniques Ior monitoring sterilization include
assessing cycle time, temperature, and pressure by
observing the gauges or displays on the sterilizer and
noting these parameters Ior each load. Some tabletop
sterilizers have recording devices that print out these
parameters. Correct readings do not ensure sterilization,
but incorrect readings can be the Iirst indication oI a
problem with the sterilization cycle.

Chemical indicators, internal and external, use sensitive
chemicals to assess physical conditions (e.g., time and
temperature) during the sterilization process. Although
chemical indicators do not prove sterilization has been
achieved, they allow detection oI certain equipment
malIunctions, and they can help identiIy procedural errors.

External indicators applied to the outside oI a package
(e.g., chemical indicator tape or special markings) change
color rapidly when a speciIic parameter is reached, and
they veriIy that the package has been exposed to the
sterilization process.

Internal chemical indicators should be used inside each
package to ensure the sterilizing agent has penetrated the
packaging material and actually reached the instruments
inside.

A single-parameter internal chemical indicator provides
inIormation regarding only one sterilization parameter
(e.g., time or temperature).
Multiparameter internal chemical indicators are designed to
react to ~2 parameters (e. g., time and temperature; or time,
temperature, and the presence oI steam) and can provide a
more reliable indication that sterilization conditions have
been met. Multiparameter internal indicators are available
onl y Ior steam sterilizers (i.e., autoclaves).

Because chemical indicator test results are received when
the sterilization cycle is complete, they can provide an
earl y indication oI a problem and where in the process the
problem might exist. II either mechanical indicators or
internal or external chemical indicators indicate inadequate
processing, items in the load should not be used until
reprocessed.

Biological indicators (BIs) (i.e., spore tests) are the most
accepted method Ior monitoring the sterilization process
because they assess it directl y by killing known highl y
resistant microorganisms (e.g., Geobacillus or Bacillus
species), rather than merely testing the physical and
chemical conditions necessary Ior sterilization.

Because spores used in BIs are more resistant and present
in greater numbers than the common microbial
contaminants Iound on patient-care equipment, an
inactivated BI indicates other potential pathogens in the
load have been killed.

Correct Iunctioning oI sterilization cycles should be
veriIied Ior each sterilizer by the periodic use (at least
weekly) oI BIs.

Waste Disposal

Disposable materials should be handled with care to protect against
exposure to potentially inIectious hazards

Option %reatment &
Disposal
Waste Category
Cat.
No. 1
Incineration /deep
burial
Human Anatomical Waste (human
tissues, organs, body parts)
Cat.
No. 2
Incineration /deep
burial
Animal Waste Animal tissues, organs,
Body parts carcasses, bleeding parts,
Iluid, blood and experimental animals
used in research, waste generated by
veterinary hospitals/ colleges, discharge
Irom hospitals, animal houses)
Cat.
No. 3
Local autoclaving/
micro waving/
incineration
Microbiology & Biotechnology waste
(wastes Irom laboratory cultures, stocks
or specimens oI micro-organisms live or
attenuated vaccines, human and animal
cell culture used in research and
inIectious agents Irom research
andindustrial laboratories, wastes Irom
productionoI biological, toxins, dishes
and devices used Ior transIer oIcultures)
Cat.
No. 4
DisinIections
(chemical
treatment
/autoclaving/micro
waving and
mutilation
shredding
Waste Sharps (needles, syringes,
scalpels blades, glass etc. that may
cause puncture and cuts. This includes
both used & unused sharps)
Cat.
No. 5
Incineration /
destruction &
drugs disposal in
secured landIills
Discarded Medicines and Cytotoxic
drugs (wastes comprising oI outdated,
contaminated and discarded medicines)
Cat.
No. 6
Incineration ,
autoclaving/micro
waving
Solid Waste (Items contaminated with
blood and body Iluids including cotton,
dressings, soiled plaster casts, line
beddings, other material
contaminated withblood)
Cat.
No. 7
DisinIections by
chemical
treatment
autoclaving/micro
waving&
mutilation
shredding.
Solid Waste (waste generated Irom
disposable items other than the waste
sharps such as tubing, catheters,
intravenous sets etc.)
Cat.
No. 8
DisinIections by
chemical
treatment and
discharge into
drain
Liquid Waste (waste generated Irom
laboratory & washing, cleaning ,
house-keeping and disinIecting
activities)
Cat.
No. 9
Disposal in
municipal landIill
Incineration Ash (ash Irom incineration
oI any bio-medical waste)
Cat.
No. 10
Chemical
treatment &
discharge into
drain Ior liquid &
secured landIill
Ior solids
Chemical Waste (chemicals used in
production oI biological, chemicals,
used in disinIect ion, as insecticides,
etc)


WAS%E DS!OSAL
Disposable Materials Should Be Handled With Care To Protect
Against Exposure To Potentially InIectious Hazards.
Yellow Plastic bags:
Cat 1 human anatomical waste,
Cat 2 animal waste,
Cat 3 microbiology waste,
Cat 6 soiled waste.
Red DisinIected
Cat 3 Microbiological
Cat 6 soiled waste
Cat 7 solid waste (Waste IV tubes catheters, etc.)
Blue/White Plastic bag/puncture prooI
Cat 4 waste sharps
Cat 7 solid waste
Black
Cat 5 discarded medicines
Cat 9 incineration ash
Cat 10 chemical waste



Dental Unit Waterlines, Biofilm, and Water Quality
Studies have demonstrated that dental unit waterlines (i.e., narrow-
bore plastic tubing that carries water to the high-speed handpiece,
air/water syringe, and ultrasonic scaler) can become colonized with
microorganisms, including bacteria, Iungi, and protozoa. Protected by
a polysaccharide slime layer known as a glycocalyx, these
microorganisms colonize and replicate on the interior surIaces oI the
waterline tubing and Iorm a bioIilm, which serves as a reservoir that
can ampliIy the number oI Iree-Iloating (i.e., planktonic)
microorganisms in water used Ior dental treatment. Although oral
Ilora and human pathogens (e.g., Pseudomonas aeruginosa,
Legionella species, and nontuberculous Mycobacterium species),
have been isolated Irom dental water systems, the majority oI
organismsrecovered Irom dental waterlines are common heterotrophic
water bacteria. These exhibit limited pathogenic potential Ior
immunocompetent persons.

Clinical mplications
Certain reports associate waterborne inIections with dental water
systems, and scientiIic evidence veriIies the potential Ior transmission
oI waterborne inIections and disease in hospital settings and in the
community InIection or colonization caused by Pseudomonas species
or nontuberculous mycobacteria can occur among susceptible patients
through direct contact with water or aIter exposure to residual
waterborne contamination oI inadequately reprocessed medical
instruments. Nontuberculous mycobacteria can also be transmitted to
patients Irom tap water aerosols. Health-careassociated transmission
oI pathogenic agents (e.g., Legionella species) occurs primarily
through inhalation oI inIectious aerosols generated Irom potable water
sources or through use oI tap water in respiratory therapy equipment.
Disease outbreaks in the community have also been reported Irom
diverse environmental aerosol producing sources, including whirlpool
spas, swimming pools, and a grocery store mist machine. Although
the majority oI these outbreaks are associated with species oI
Legionella and Pseudomonas, the Iungus Cladosporium has also been
implicated.
Researchers have not demonstrated a measurable risk oI adverse
health eIIects among DHCP or patients Irom exposure to dental water.
Certain studies determined DHCP had altered nasal Ilora or
substantially greater titers oI Legionella antibodies in comparisons
with control populations; however, no cases oI legionellosis were
identiIied among exposed DHCP. Contaminated dental water might
have been the source Ior localized Pseudomonas aeruginosa inIections
in two immunocompromised patients.
Although transient carriage oI P. aeruginosa was observed in 78
healthy patients treated with contaminated dental treatment water, no
illness was reported among the group. In this same study, a
retrospective review oI dental records also Iailed to identiIy
inIections.
Concentrations oI bacterial endotoxin 1,000 endotoxin units/mL
Irom gram-negative water bacteria have been detected in water Irom
colonized dental units. No standards exist Ior an acceptable level oI
endotoxin in drinking water, but the maximum level permissible in
United States Pharmacopeia (USP) sterile water Ior irrigation is only
0.25 endotoxin units/ mL. Although the consequences oI acute and
chronic exposure to aerosolized endotoxin in dental health-care
settings have not been investigated, endotoxin has been associated
with exacerbation oI asthma and onset oI hypersensitivity
pneumonitis in other occupational settings.


Radiographic asepsis
When taking radiographs, the potential to cross-contaminate
equipment and environmental surIaces with blood or saliva is high iI
aseptic technique is not practiced. Gloves should be worn when taking
radiographs and handling contaminated Iilm packets. Other PPE (e.g.,
mask, protective eyewear, and gowns) should be used iI spattering oI
blood or other body Iluids is likely. Heat-tolerant versions oI intraoral
radiograph accessories are available and these semicritical items (e.g.,
Iilm-holding and positioning devices) should be heat sterilized beIore
patient use.
AIter exposure oI the radiograph and beIore glove removal, the Iilm
should be dried with disposable gauze or a paper towel to remove
blood or excess saliva and placed in a container (e.g., disposable cup)
Ior transport to the developing area. Alternatively, iI FDA-cleared
Iilm barrier pouches are used, the Iilm packets should be careIully
removed Irom the pouch to avoid contamination oI the outside Iilm
packet and placed in the clean container Ior transport to the
developing area.
Various methods have been recommended Ior aseptic transport oI
exposed Iilms to the developing area, and Ior removing the outer Iilm
packet beIore exposing and developing the Iilm. Other inIormation
regarding dental radiography inIection control is available. However,
care should be taken to avoid contamination oI the developing
equipment.
Protective barriers should be used, or any surIaces that become
contaminated should be cleaned and disinIected with an EPA-
registered hospital disinIectant oI low- (i.e., HIV and HBV claim) to
intermediate-level (i.e., tuberculocidal claim) activity. Radiography
equipment (e.g., radiograph tubehead and control panel) should be
protected with surIace barriers that are changed aIter each patient. II
barriers are not used, equipment that has come into contact with
DHCP`s gloved hands or contaminated Iilm packets should be
cleaned and then disinIected aIter each patient use.
Digital radiography sensors and other high-technology instruments
(e.g., intraoral camera, electronic periodontal probe, occlusal
analyzers, and lasers) come into contact with mucous membranes and
are considered semicritical devices.
They should be cleaned and ideally heat-sterilized or highlevel
disinIected between patients. However, these items vary by
manuIacturer or type oI device in their ability to be sterilized or high-
level disinIected. Semicritical items that cannot be reprocessed by
heat sterilization or high-level disinIection should, at a minimum, be
barrier protected by using an FDA cleared barrier to reduce gross
contamination during use. Use oI a barrier does not always protect
Irom contamination. One study determined that a brand oI
commercially available plastic barriers used to protect dental digital
radiography sensors Iailed at a substantial rate. This rate dropped to
6 when latex Iinger cots were used in conjunction with the plastic
barrier. To minimize the potential Ior device-associated inIections,
aIter removing the barrier, the device should be cleaned and
disinIected with an EPA registered hospital disinIectant (intermediate-
level) aIter each patient. ManuIacturers should be consulted regarding
appropriate barrier and disinIection/sterilization procedures Ior digital
radiography sensors, other high-technology intraoral devices, and
computer components.


Dental Laboratory Asepsis
Dental prostheses, appliances, and items used in their Iabrication
(e.g., impressions, occlusal rims, and bite registrations) are potential
sources Ior cross-contamination and should be handled in a manner
that prevents exposure oI DHCP, patients, or the oIIice environment
to inIectious agents. EIIective communication and coordination
between the laboratory and dental practice will ensure that appropriate
cleaning and disinIection procedures are perIormed in the dental
oIIice or laboratory, materials are not damaged or distorted because oI
disinIectant overexposure, and eIIective disinIection procedures are
not unnecessarily duplicated.
When a laboratory case is sent oII-site, DHCP should provide written
inIormation regarding the methods (e.g., type oI disinIectant and
exposure time) used to clean and disinIect the material (e.g.,
impression, stone model, or appliance). Clinical materials that are not
decontaminated are subject to OSHA and U.S. Department oI
Transportation regulations regarding transportation and shipping oI
inIectious materials.
Appliances and prostheses delivered to the patient should be Iree oI
contamination. Communication between the laboratory and the dental
practice is also key at this stage to determine which one is responsible
Ior the Iinal disinIection process. II the dental laboratory staII
provides the disinIection, an EPAregistered hospital disinIectant (low
to intermediate) should be used, written documentation oI the
disinIection method provided, and the item placed in a tamper-evident
container beIore returning it to the dental oIIice. II such
documentation is not provided, the dental oIIice is responsible Ior
Iinal disinIection procedures.
Dental prostheses or impressions brought into the laboratory can be
contaminated with bacteria, viruses, and Iungi. Dental prostheses,
impressions, orthodontic appliances, and other prosthodontic
materials (e.g., occlusal rims, temporary prostheses, bite registrations,
or extracted teeth) should be thoroughly cleaned (i.e., blood and
bioburden removed), disinIected with an EPA-registered hospital
disinIectant with a tuberculocidal claim, and thoroughly rinsed beIore
being handled in the in-oIIice laboratory or sent to an oII-site
laboratory. The best time to clean and disinIect impressions,
prostheses, or appliances is as soon as possible aIter removal Irom the
patient`s mouth beIore drying oI blood or other bioburden can occur.
SpeciIic guidance regarding cleaning and disinIecting techniques Ior
various materials is available. DHCP are advised to consult with
manuIacturers regarding the stability oI speciIic materials during
disinIection.
In the laboratory, a separate receiving and disinIecting area should be
established to reduce contamination in the production area. Bringing
untreated items into the laboratory increases chances Ior cross
inIection. II no communication has been received regarding prior
cleaning and disinIection oI a material, the dental laboratory staII
should perIorm cleaning and disinIection procedures beIore handling.
II during manipulation oI a material or appliance a previously
undetected area oI blood or bioburden becomes apparent, cleaning
and disinIection procedures should be repeated. TransIer oI oral
microorganisms into and onto impressions has been documented.
Movement oI these organisms onto dental casts has also been
demonstrated. Certain microbes have been demonstrated to remain
viable within gypsum cast materials Ior 7 days. Incorrect handling oI
contaminated impressions, prostheses, or appliances, thereIore, oIIers
an opportunity Ior transmission oI microorganisms.
Whether in the oIIice or laboratory, PPE should be worn until
disinIection is completed. II laboratory items (e.g., burs, polishing
points, rag wheels, or laboratory knives) are used on contaminated or
potentially contaminated appliances, prostheses, or other material,
they should be heat-sterilized, disinIected between patients, or
discarded (i.e., disposable items should be used). Heat-tolerant items
used in the mouth (e.g., metal impression tray or Iace bow Iork)
should be heat-sterilized beIore being used on another patient. Items
that do not normally contact the patient, prosthetic device, or
appliance but Irequently become contaminated and cannot withstand
heat-sterilization (e.g., articulators, case pans, or lathes) should be
cleaned and disinIected between patients and according to the
manuIacturer`s instructions. Pressure pots and water baths are
particularly susceptible to contamination with microorganisms and
should be cleaned and disinIected between patients. In the majority oI
instances, these items can be cleaned and disinIected with an EPA
registered hospital disinIectant. Environmental surIaces should be
barrier-protected or cleaned and disinIected in the same manner as in
the dental treatment area. Unless waste generated in the dental
laboratory (e.g., disposable trays or impression materials) Ialls under
the category oI regulated medical waste, it can be discarded with
general waste. Personnel should dispose oI sharp items (e.g., burs,
disposable blades, and orthodontic wires) in puncture-resistant
containers.













SUMMARY
Though all oI us are in agreement that sterility is a must in medical
history & dental practice , the subject is more complex than it
appears with respect to protection oI staII , patients & environment
.Aseptic practice & sterile techniques are based on the method oI
sterilization which can be easily be adapted to the private dental
oIIice. Any technique is as good as the person who is carrying it out.
There is no single method that is the absolute answer to all the
sterilization problems.

Sterility oI the oral cavity cannot be achieved. The main concern Ior
the dentist is to prevent the introduction oI inIections and to eliminate
transIer oI organisms Irom one patient to another. The practitioner
must be able to provide sterile items using whatever means are at
hand Ior sterilization. It is necessary that the practitioner understand
the principles oI sterilization & disinIection methods to saIe &
eIIicient patient case & aseptic practice.