Disinfection & Antiseptics

Introduction
Early civilizations practiced salting, smoking, pickling, drying, and exposure of food and clothing to sunlight to control microbial growth. Use of spices in cooking was to mask taste of spoiled food. Some spices prevented spoilage. In mid 1800s Lister helped developing aseptic techniques to prevent contamination of surgical wounds. Before then:
Nosocomial infections caused death in 10% of surgeries. Up to 25% mothers delivering in hospitals died due to infection

Definitions
Sterilization: Killing or removing all forms of microbial life in a material or an object. Kills spores (most heat resistant microbe) Heating is the most commonly used method of sterilization. Disinfection: Reducing the number of pathogenic microorganisms to the point where they no longer cause diseases. Spores are not destroyed Disinfectant: Applied to inanimate objects (work surfaces). Antiseptic: Applied to living tissue (dentists
hands).

CROSS-CONTAMINATION

Passage of microorganisms from one person or inanimate object to another

Aseptic techniques* must be implemented to reduce occurrence Aseptic techniques are used to prevent contamination of surgical instruments, medical personnel, and the patient during surgery.

Aseptic techniques are also used to prevent bacterial contamination in food industry.

Why Is Infection Control Important in Dentistry?

Both patients and dental health care personnel (DHCP) can be exposed to pathogens Contact with blood, oral and respiratory secretions, and contaminated equipment occurs Proper procedures can prevent transmission of infections among patients and DHCP

Modes of Transmission

Direct contact with blood or body fluids Indirect contact with a contaminated instrument or surface Contact of mucosa of the eyes, nose, or mouth with droplets Inhalation of airborne microorganisms

CHAIN OF INFECTION
All links must be connected for infection to take place
(sufficient virulence & adequate numbers)

Pathogen

Susceptible Host

(i.e., one that is not immune)

(allows pathogen to survive & multiply)

Source

Entry
(portal that the pathogen can enter the host)

Mode
(of transmission from source to host)

Microbial Characterisation and control

Most resistant
Bacterial Endospores Mycobacteria Cysts of Protozoa Vegetative protozoa Gram-negative bacteria Fungi, incl. spores Virus without envelope Gram-positive bacteria

Least resistant

Virus with lipid envelope

Precleaning and Disinfection

Precleaning means to clean before disinfecting. All contaminated surfaces must be precleaned before they can be disinfected. Even if there is no visible blood on the surface, it must be precleaned because even a thin layer of saliva on the surface can decrease the effectiveness of the disinfectant. Precleaning reduces the number of microbes and removes blood and saliva (also called bioburden). Regular soap and water may be used for precleaning, but it is more efficient if you select a disinfectant that has the ability to clean as well as disinfect.

DISINFECTION
Low-level
Does not kill spores or M. tuberculosis

Intermediate-level
Kills M. tuberculosis, not necessarily spores

High-level
Kills M. tuberculosis, kills some spores

Disinfectants
In dentistry, only those products that are Environmental Protection Agency (EPA)registered hospital disinfectants with tuberculocidal claims (kills the tuberculosis bacteria) should be used to disinfect dental treatment areas. The Mycobacterium tuberculosis is highly resistant to disinfectants, and if a disinfectant will inactivate the M. tuberculosis, it will most certainly inactivate the less resistant microbial families (such as bacteria, viruses, and most fungi) on the treated surface.

IDEAL DISINFECTANT
Broad spectrum Fast acting Surface compatibility Residual effect

Non toxic
Hypoallergenic Not affected by physical factors

Easy to use
Odorless Economical

The Perfect Disinfectant?

Unfortunately, no single disinfectant product on the market today meets all these criteria. When selecting a surface disinfectant, you must carefully consider the advantages and disadvantages of various products. Often the manufacturers of dental equipment will recommend the type of surface disinfectant that is most appropriate for their dental chairs and units.

Factors influencing chemical disinfection.

Nature of the microbes
Gram ve, Gram +ve, mycobacteria, endospores

Time of exposure Concentration of chemical Numbers and location of microorganism Temperature Environmental pH
affect chemical

Interfering substance
organic material

Humidity

Why dentists use antiseptics?

Skin preparation before surgery Preoperative preparation of the oral mucosa Inhibition of dental plaque Cleaning operating areas Cold sterilization of the equipment where heat sterilization is impractical Storage of sterilized surgical equipments Preparation of the surgeon's and assistants hands Irrigation of root canals in endodontics

Antiseptics are used in dentistry

As components of mouthwashes As components of toothpastes As disinfectants As an aid of sterilization For skin and mucosal cleansing prior to surgery

Mechanism of Action
Denaturation of proteins
Acids, oxidising agents, heavy metals (mercury)

Reactions that affects membranes

Dissolve lipids - alcohols, phenols

Reactions with other cell components

nucleic acid - alkylating agents

Specific chemical antimicrobial agents

Alcohols

Aldehydes
Bis-Biguanides Halogens Oxidising agents Phenols Surface active agents (surfactants)

Types of Antiseptics/Disinfectants
1. Alcohols:

Kill bacteria, fungi, but not endospores (limited usefulness) or viruses. Act by denaturing, precipating proteins and disrupting cell membranes. Evaporate, leaving no residue. Used to mechanically wipe microbes off skin before injections or blood drawing. Not good for open wounds, because cause proteins to coagulate. Ethanol (ethyl alcohol): Optimum concentration is 70%. Higher concentrations are useless. Isopropanol: Rubbing alcohol. Better disinfectant than ethanol. Also cheaper and less volatile.

Alcohols
are not effective in the presence of blood and saliva which give protection of the microorganism. They are damaging to certain materials such as plastics and vinyl. Alcohols can act as vehicles for other antiseptics such as chlorhexidine and increaaes its activity. They are ineffective in oral mucosa
The American Dental Association (ADA), CDC, and the Office of Safety and Asepsis Procedures Research Foundation (OSAP) do not recommend alcohol as an environmental surface disinfectant.

2. Aldehydes:
Inactivate

proteins by forming covalent crosslinks with several functional groups. A. Formaldehyde Excellent disinfectant against bacteria, fungi and viruses. Its action is very slow (at 0.5% conc, it takes 12 hours to
kill bacteria)

Used

in concentrations of 2-8% to disinfect inanimate objects. Commonly used as formalin, a 37% aqueous solution. Irritates mucous membranes, strong odor. Fairly toxic

B. Glutaraldehyde: Less irritating, less volatile, less odor and more effective than formaldehyde. One of the few chemical disinfectants that is a sterilizing agent (cold sterilization). A 2% solution of glutaraldehyde (Cidex) is:
Bactericidal, tuberculocidal, and viricidal in 10 minutes. Sporicidal in 3 to 10 hours. Unlike alcohol, it is not inactivated by biological fluids

Commonly used to disinfect hospital instruments that can not be autoclaved and contaminated by viruses Should be applied for at least 1 hour-12 hours

3- Bis-Biguanides
Antiseptic and disinfectant They are cationic surface-acting agents that interfere with cell membrane permeability. Best known chlorhexidine Preparations: - Skin (1-4 % solution) for preparation of surgical sites - Intra-oral: chlorhexidine-containing toothpaste (1%), - oral rinses (0.2%) mixed with cetrimide (Savlon) Very effective in alcoholic solutions Acts on gram positive and negative bacteria but No good against bacterial spores or viruses

4- Halogens React with micro-organism proteins and inactivate enzymes Used as disinfectant but mostly not in a health-care environment (mainly at houses) A. Iodine Antiseptic in much the same way as chlorine but it is not readily inactivated by organic matter Weak iodine solution (2.5% iodine in potassium iodine) Applied to skin before surgery Toxic , hypersensitivity and stains

B. Chlorine: When mixed in water forms hypochlorous acid: Cl2 + H2O ------> H+ + Cl+ HOCl
Hypochlorous acid

Active

against bacteria (including spores), viruses and fungi. Chlorine is easily inactivated by organic materials from bacterial proteins. Sodium hypochlorite (NaOCl): - Higher concentrations (Clorox) are used as household bleach - 2% is used in dentistry as an antiseptic and irrigant of root canals and as an effective solvent of necrotic tissues such as a dead pulp.

5- Iodophors (iodine-containing compounds)

Povidone-iodine - combination of iodine and surfaceactive detergent - Do not irritate or stain (water-soluble) the skin - Active against g+ and g- bacteria in 15 seconds, kills spores after prolong exposure, also against viruses and fungi - Mouth wash (1%) for mucosal infection in the form of diluted or undiluted form with warm water.

6- Peroxygens (Oxidizing Agents):

Oxidize cellular components of treated microbes by liberating oxygen. Disrupt membranes and proteins. Their action is finished as the oxygen is used up. Their advantage: non-toxic A . Hydrogen Peroxide: Used as a weak antiseptic. Mouthwash in acute ulcerative gingivitis. 30% aqueous solution is used to bleach discolored root-filled teeth. Not good for open wounds because quickly broken down by catalase present in human cells. Sporicidal at higher temperatures. B. Sodium perborate in acute ulcerative gingivitis: Liberation of oxygen when contacting organic matter.

7- Phenols and Phenolics

Phenol (carbolic acid) was first used by Lister as a disinfectant.

Rarely used today because it is a skin irritant, burning and has strong odor. Used in some throat sprays and lozenges. At weak solutions, it acts as local anesthetic so widely used in mouthwash.

Phenolics are chemical derivatives of phenol

Cresols: - three times of the bactericidal potency of phenol and is about as toxic. - Metacresyl acetate is a Cresol derivative and used in in the irrigation of root canals Chloroxylenols - the least effective of phenols and activity is considerably reduced in organic matters - 5% is the Dettol - Liable to be contaminated by Pseudomonas pyocyanea and increase its growth

Hexachlorophene - Effective against gram-positive staphylococci and streptococci. Used in nurseries. Excessive use in infants may cause neurological damage. Triclosan - incorporated into soaps and toothpastes. - antimicrobial and anti-inflammatory action Camphorated paramonochlorphenol (CMCP) - Its disinefectant activity is related to the release of chlorine in the presence of phenol - 1% parachlorphenol solution .

8-Surface active agents (surfactants) They have both fat and water soluble groups in the same molecule. Classified based on the electric charge on that group. Come in 4 types cationic (positive), anionic (negative), non-ionic and amphoretic (negative and positive) agents Anionic and non-ionic weak antimicrobials

Cationic agents Most commonly is the Quaternary Ammonium Compounds (Quats): Widely used surface active agents. Inhibited by organic matter Act as detergents by interacting with membrane lipids and proteins. Effective against gram positive bacteria, less effective against gram-negative bacteria. Also destroy fungi, amoebas, and enveloped viruses. Cetrimide is a common agent used in this group Cetrimide (15%) is combined with chlorhexidine 1.5% in a solution called Savlon which is used as a general antiseptic Generally weak antiseptic but used as antiplaque agents in dentistry

http://www.ada.org/ American Dental Association Website, up-to-date and useful information