Sterilization And Disinfection in

Orthodontics

GUIDED BY : Presented by
DR. SANDHYA JAIN Dr. Anil k Bunkar
(PROF. & HEAD) 1st year P.G. student
Dept. of Orthodontics Dept. of Orthodontics

DATE 30/10/19
• Microorganisms are omnipresent

• Pathogenic microbes may be transmitted directly from

the dentist to the patient or from the patient to the
dentist, and indirectly from patient to patient.

• Thus ,it is necessary to remove them as they cause

contamination , infection and decay.

• This presents an enormous challenge in the current

scenario as it has been proved that blood and saliva are high
risk sources of contracting hepatitis b, human
immunodeficiency virus and herpes.
• Sterilization is defined as the process by which an article,
surface or medium is freed by all living micro- organisms
either in vegetative or spore state.

• Disinfection- means the destruction or removal of all

pathogenic organisms or organisms capable of giving rise
to infection.

• Antisepsis- used to indicate the prevention of infection,

usually by inhibiting the growth of bacteria in wounds or
tissues.

• Antiseptics- Chemical disinfectants which can be safely

applied to skin or mucous membrane and are used to
prevent infection by inhibiting the growth of bacteria.
• Bactericidal/germicidal- are those which are able to kill
bacteria.

• Bacteriostatic- are agents only that prevent

the multiplication of bacteria which may
however remain alive.

• Decontamination- refers to the process of rending an article

or area free of danger from contaminants including microbial,
chemical, radioactive and other hazards.

• Fumigation- exposure of an area or

object to disinfectant, insecticidal or vermin killing fumes.
Sterilization
 Sterilising
methods

PHYSICAL CHEMICAL

Alcohols
Sunlight, Aldehydes
Drying , Dyes
Dry heat, Halogens
Moist heat Phenols
Filtration Surface active
agents
Radiation and
. Metallic salts
Ultrasonic
Gases
sonic vibration
 ORTHODONTIC IMPLICATIONS OF CURRENT STERILIZATION
PROTOCOLS AND
STERILIZATION INDUCED INSTRUMENT DAMAGE

• The advice sheet issued for infection control in dentistry issued,

from the department of health, united kingdom enumerates
three stages to sterilization or the decontamination process
namely;
 pre-sterilization cleaning
 sterilization and
 storage.
 Pre-sterilization Cleaning

• All instruments must be thoroughly cleaned (debrided) of

contaminants (blood, saliva and other impurities)before under going
a sterilization cycle.
• As the retention of these contaminants and debris may shield the
organisms from the sterilization protocol intended to kill them.
• Pre-cleaning protocols remove a large number of organisms when
carried out thoroughly.
 Method of Pre-sterilization Cleaning

Conventional method
 involved initial debridement of all instruments By Hand aided by
a brush and detergent under running water.
 cost-effective but the hand cleaning process not only poses a risk
of infection to the personnel but is also time consuming.
 present day automated equipments method

 involve the use of ultrasonic baths and instrument washer /

disinfectors.
 direct precleaning in specially designed containers and cassettes.
 Special solutions have been recommended in their use; having
anti-rust compositions and enzyme based for maximum
effectiveness in the breakdown of contaminants and particles.
 Pre-cleaning cycles usually last between 5 -15 minutes, depending
on the instrument load.
 reduce the chances of instrumental damage without a compromise
on the quality of sterilization achieved.
 important point regarding the pre-cleaning
stage

• important point to that any traces of residual moisture is eliminated

through appropriate drying measures (compressed air).
• The presence of moisture especially between the joints and tips
(serrated) of instruments increases the corrosive tendency in
instruments
 Sterilization - Common Types, Mechanism of Action and Orthodontic
considerations

• Autoclaving or Steam under Pressure Sterilization

 Autoclaving is the gold standard for effective sterilization and is employed

for most surgical needs.
 Effective against all fungi, bacteria, viruses and spores.

• Conventional method
15 minutes at 121 °C under 15 psi pressure
• Rapid cycle method
3 minutes at 134°C is required under 15 psi pressure

• Following sterilization, a cooling down period is usually ranges from 40

minutes to 1 hour for Rapid and Conventional Cycles.
• Although extremely effective as a form of sterilization, the presence
of steam vapor in the process has been found to be detrimental for
orthodontic pliers
• Corrosive changes were found to occur around hinge areas, sharp
angles, cutting edges or pointed ends that facilitated the retention
of water vapor.
 Dry Heat and Rapid Dry Heat Sterilization process.
• Effective against all fungi, bacteria, viruses and spores.
• Best suited for orthodontic needs due to the absence of moisture.
• Repeated Heat cycles can alter surface hardness characteristics of
instruments

• Conventional dry heat sterilization

temperature of 160°C (320°F) for 2 hours to achieve complete
sterilization.

• Rapid Dry-Heat Sterilization

temperatures of 190°C (375°F) for 6 to 12 minutes. Also known as
present day hot-air sterilization.
• Instruments must be dry before sterilization, as the presence of
water will interfere with the process.
• The absence of moisture in the sterilization process is beneficial to
the longevity of orthodontics pliers, the cutting surfaces; thereby
making it advantageous over other sterilization protocols

• higher temperatures associated with this process can predispose to

some changes in the physical properties of the plier exposures
above 380°F (193°C).
• Long-term effects of repeated dry-heat sterilization have reported
minimal changes in the physical characteristics of orthodontic pliers
where corrosion and micro-hardness were evaluated.
 Chemical Vapor Sterilization or Chemiclave
• Effective against all fungi, bacteria, viruses and spores.
• Preserves instrument integrity but causes dulling.
• Not a practical option in dental offices.

• Chemical vapor steriIization is carried out at a pressure of 20 psi

and temperature of 132°C sterilization time is 20 minutes.
• solution of various alcohols, acetone, ketone,formaldehyde (0.23%)
and distilled water (9.25%).
• dulling is seen with long-term use.
• orthodontist's viewpoint it has not gained popularity due to the
presence of a strong odor.
 Chemical Immersion or Cold Sterilization
• Recommended only for heat-sensitive nonsurgical instruments and
alginate impressions
• Prolonged immersion time required for effectiveness
• No method to verify effective sterilization
• Predisposes to Pitting type corrosion in orthodontic instruments.

• 2% acidic glutaraldehyde (Banicide) and chlorine dioxide are

commonly used sterilants which are ADAapproved.

• Sterilization time with 2% acidic glutaraldehyde is 10 hours without

dilution and with chlorine dioxide (Exspor 4:1:1) is 6 hours when
mixed according to the manufacturer's instructions.
Glass Bead Sterilization
• Use limited to orthodontic bands
• Higher temperatures can be deleterious for orthodontic plier tips

• Glass bead sterilization uses small glass beads ranging from 1.2 to
1.5mm in diameter.
• The heating range is 424°F to 450°F (217°C to 232°C) for 3 to 5
seconds but not exceeding 482 °F (250°C).

• The larger the instrument, the longer the heat-up time required.

• Molar band sterilization reported spore effectiveness at 226°after

45 seconds for a single band.
• Additional numbers will concomitantly increase this time duration
with a strong possibility of altering the physical characteristic of the
band.
Sterilization Induced Instrument Damage - Contributory Factors and
Misconceptions

1. Water Quality: pH imbalances and harmful, higher mineral content

are known to cause corrosion in instruments.
2. Strong Detergents: Promote the precipitation of proteins on
instruments which can be difficult to remove and in turn act as local
foci from where corrosion can be initiated in the presence of other
promoters of corrosion.
3. Excessive Heat Exposure: An increased temperature exposure above
current manufacturer recommendation of 380°F (193°C) is not
advisable. Please note that this is only for the newer generation of
pliers manufactured to meet the demands of current recommended
sterilization protocols involving dry-heat sterilizers; Older and
cheaper quality pliers would not even qualify for this method of
sterilization.
4. Presence of moisture: Improper drying following precleaning in
pliers and instruments during sterilization is one of the most
important factors for corrosion. All instruments must be thoroughly
dried prior to dry heat sterilization. Moisture centric protocols like
autoclaving are deleterious and not recommended for sterilization
of instruments.
5. Chemical Immersion or Cold sterilization : Instruments sterilized
through this process are reported to be associated with pitting type
corrosion which can be very damaging.
6. Disinfectant Compositions: Chemical solutions and Enzymatic
cleaning solutions are presently not recommended due to their
corrosive effects.
7. Cheap quality pliers: Cheaper pliers generally indicate poor alloying
elements and additionally poor milling qualities, which are
attributes conducive to corrosion.
8. Damaged instruments : Sterilization accelerates corrosion in
instruments which already have compromised physical
characteristics and surface irregularities.
 PRACTICAL GUIDELINES FOR IMPLEMENTING INSTRUMENT
STERILIZATION
IN THE ORTHODONTIC OFFICE

• The recommended guidelines for orthodontic sterilization

requirements are outlined for maximum effectiveness while
preserving instrument integrity.

• Essential requirements for implementing and maintaining effective

infection control standards in your orthodontic office:-
• Primary protocol
1. Ultrasonic Unit (for debridement and pre cleaning protocols)
2. Dry-Heat Sterilizer
3. Desktop Autoclave Sterilizer
• Secondary protocol
chemical disinfectants as well as alcohol based wipes is
recommended only for instruments and materials which do not
come into direct contact with the patient and where cross
contamination risks are not involved.
• Guidelines for Sterilization of Orthodontic Pliers: -
1. Ultrasonic cycle for 5 to 12 minutes depending on the capacity of
the unit.
2. Rinsing with Distilled Water.
3. Remove excess moisture thorough drying with Compressed Air (Oil-
Free).
4. Lubrication of plier joints and cutting surfaces with silicone based
lubricants.
5. Sterilization protocol using a Dry-Heat Sterilizer at 190°c(375°f) for 6
to 12 minutes with the placement of pliers in an open.
6. Storage

• Autoclaving is recommended only if a dry heat sterilizer is not

available and only as a secondary option to dry heat
sterilization.
• For Prion elimination, recommendations have advocated autoclave
cycles at 121 degree for 60 minutes or 134 degree for at least 18
minutes or combination cycles involving hot-air sterilization
followed by autoclaving to improve the margin of the safety
• Recommendations for sterilization of Pre-formed orthodontic
bands for both the in-received state as well as tried- in ones.
1. Ultrasonic cycle for 5 minutes depending on the capacity of the unit.
2. Rinsing with Distilled Water.
3. Remove excess moisture thorough drying with Compressed Air (Oil-
Free).
4. Sterilization protocol using a Dry-Heat Sterilizer at 190°C (375°) for 6
minutes.
5. Storage.
• Autoclaving of preformed molars bands can also be carried
out as an alternative to dry heat sterilization as the smooth
surface of the band does not leave any scope for moisture
retention but Pre-formed bands having welded counterparts
are not recommended for autoclaving.
• Guidelines for elastomeric and elastomeric ligatures
• Elastomeric and elastomeric Ligatures are not suited for chemical
disinfection as they are known to alter the physical characteristics.
Alcohol wipes are not an alternative as they are not effective in the
presence of tissue proteins seen in blood and saliva.
• Single patient packs are the best insurance against cross-
contamination risks at present and where this is not feasible as in
the case of e-chain spools, it is better to cut a little extra than
required and discard the rest.
• Guidelines for sterilization of alginate impressions:-
1. Rinse thoroughly under running water following removal.
2. Immersions of impression in disinfectant for 10 minutes.
3. Rinse again under running water.
4. Ready for model processing.

This impression can be processed for model fabrication. Additionally

this recommendation is suited for orthodontic appliances as well.
 Disinfection of orthodontic brackets

• Chlorhexidine (0.01 %)is an appropriate disinfectant to be used on

metal or ceramic brackets as it does not have a significant effect on
the metal brackets’ adhesion ability.
 Sterilization of orthodontic wires

• Pernier et al (2005) observed the sterilization of 6 different arch

wires by autoclaving them for 18 minutes in 134ºC via surface
analysis techniques.
• No significant change was observed on the alloys surface
characteristics that would affect their utilization
 Conclusion

• As the age old saying “Prevention is better than cure” goes,

detailed understanding of the application of the sterilization will
help ensure safety from the invisible but deadly world of microbial
pathogens.
• Hence utilization of proper sterilization, disinfectants and aseptic
procedures will help us to achieve the safety of our professional
demands.
Thank you