Sterilization

and
disinfection
1

Contents
Introduction
Definitions
Objectives
Instrument

cleaning step
Packaging step
Method of sterilization
Test for sterilization
Care of sterile Instruments
2

Disinfectants
Preparation of treatment room
Unit water lines
Patient preparation
Occupational Accidental Exposure
Management
Conclusion
References
3

Micro organisms are ubiquitous. Since

they cause contamination, infection
and decay , it becomes necessary to
remove or destroy them from materials
or from areas.

Sterilization procedures used in

dentistry should be simple but effective
and of relatively short duration.
4

LOUIS

PASTEUR of France was

among the first to use sterilization
techniques, he developed the steam
sterilization, hot air oven and the
autoclave. Pasteurization was a
method developed by him to rid of
tubercle bacilli from milk.
JOSEPH LISTER, applied Pasteur's
work and introduced antiseptic
technique in surgery (1867). He is
the father of antiseptic surgery.

STERILIZATION :
Is defined as the process by which an
article, surface or medium is freed of all
living microorganisms either in the
vegetative or in the spore form.
DISINFECTION :
It is the destruction or removal of all
pathogenic organisms to a level which
seems to be no longer harmful to health.
6

SEPSIS

Refers to presence of infection, infectious material

or agent

ASEPSIS

freedom from infection,

prevention of contact with pathogens

INFECTION :
Invasion of the body tissues by the pathogenic
bacteria

INFECTION CONTROL :
Prevention

of spread of micro-organisms from

their hosts
Killing or removal of micro-organisms from
objects and surfaces

CONTAMINATION :
Contamination is the presence of a minor and
unwanted constituent in a material, in a
physical body, in the natural environment, at a
workplace, etc. .

Decontamination:
It is the process of removal of contaminating
pathogenic microorganisms from the articles by a
process of sterilization or disinfection

ANTISEPTIC

Refers to a chemical agent that is used on or in

living tissues to kill or prevent the growth of
microbes.

AEROSOL:
Invisible airborne particles dispersed into the
surrounding environment by dental equipment
(e.g., handpieces, electronic instruments).

10

OBJECTIVES

11

TREATMENT ROOM
FEATURES

12

DENTAL CHAIR
Controls

all foot operated

If

manually operated needs disposable

cover for buttons
Surface

should be made up of plastic

material that withstand chemical
disinfection without damage or
discoloration .
13

14

LIGHT
Foot

operated switches

Removable

handle for sterilization or

disposable barrier control

15

CLINICIAN STOOL
Smooth

, plastic material that is easily

disinfected and has a minimum of
seams and creases
Foot

operated controls

16

FLOOR
Carpeting

should be avoided

Floor

covering should be smooth ,

easily cleaned and non absorbent.

17

SINK
Smooth

material (stainless steal)

Wide

and deep for effective hand

washing without splashing
Water

faucets and soap dispensers

with electric knee or foot controlled

18

WASTE
Heavy

duty plastic bags linear to be

sealed tightly for disposal.

19

20

CLEANING STEP
ULTRASONIC

PROCESSING

MANUAL PROCESSING

PACKAGING STEP
21

MANUAL CLEANING
PROCESSING
cleaning of instrument should be done
before sterilization

22

PROCEDURE
Wear

heavy duty gloves and mask

Dismantle
Use

instruments

detergent and scrub

Brush

with strokes away from the body

Rinse

thoroughly

Dry

on paper towel

23

ULTRASONIC PROCESSING
STEP
Ultrasonic cleaning prior to sterilization is safer
than manual cleaning

24

ADVANTAGES
Increased
Reduced

contact

efficiency

danger to clinician from direct

Penetration

into areas of instruments

where the bristle of a brush may be unable
to contact
Removal

of tarnish
25

Procedure
Instrument
Dismantle

must be completely immersed

instruments with detachable

parts
Time

accurately by manufacturers guide

Drain

, rinse and air dry

26

Often instruments are packed for sterilization to

be stored and handled without being
contaminated.
Packing depend on the intended shelf life after
sterilization.
The available packing options are:

Textile has shelf life of 1 month

Paper has shelf life of 1 6 months
Nylon, glass, and metal have shelf life of 1 year if
tightly closed
27

Tips on wrapping and

packaging
Make

sure the instruments dont protrude

from package.

more

than two layers of wrap.

Place

biologic or chemical indication along

with packages.

28

29

Physical agents
1. sunlight
2. drying
3. dry heat
- red heat
- flaming
- incineration
- hot air oven
- glass bead sterilization
- ethylene oxide Gas Sterilization
30

4. moist heat
- pasteurization
- boiling
- steam under normal pressure
- steam under pressure
5. filtration
- candles
- asbestos pad
- membranes
6. radiation
7. ultrasonic and sonic vibrations
31

Chemical agents
1. alcohols
- ethyl alcohol
- isopropyl alcohol
- trichloro butanol
2. aldehydes
- formaldehyde
- glutaraldehyde
3. dyes
4. halogens
5. surface active agents
6. metallic salts
7. gases
32

Sunlight possess appreciable bacterial

activity and plays an important role in the
spontaneous sterilization that occurs
under normal conditions

The action is mainly due to UV rays

Direct sunlight has germicidal activity.

33

Moisture is essential for growth of

bacteria.

Drying in air has therefore a deleterious

effect.

This is unreliable, spores are unaffected.

34

The factors influencing sterilization by heat

are
1.Nature of heat.
2.Temperature and time
3.Number of microorganisms
4.Characteristics of organisms
5.Type of material from which organisms
have to be eradicated.

35

Red Heat
sterilized by holding them in
Bunsen flame till they become
red hot.
USE :
bacteriological loops
straight wires
tips of forceps and searing
spatulas
36

This is a method of passing

the article over a Bunsen
flame, but not heating it to
redness,

USE :
Scalpels
mouth of test tubes,
Flasks
glass slides
cover slips

37

This is a method of
destroying contaminated
material by burning them
in incinerator.

USE :
soiled

dressings
animal carcasses
pathological material
bedding etc
38

This is the most widely used

method of sterilization by dry
heat.
TEMPRATURE

TIME (minutes)

160 c

120

170 c

60

150 c

150

140 c

180
39

Advantages:1.Is effective and safe for sterilization of

metal instruments and mirrors.
2. Does not dull cutting edges.
3. Does not rust or corrode.

40

Disadvantages:1.Requires

long cycle for sterilization except

for forced air.
2.Has poor penetration.
3.May discolor and char fabric.
4.Destroys heat labile items.
5.Cannot sterilize liquids.
6.Unsuitable for hand pieces.
7.Cooling of the oven takes a long time.
41

Uses:
Forceps
Scissors
Scalpels
Swabs
glass ware
petri-dishes
Pipettes
Flasks
all glass syringes.
Pharmaceuticals products

like Liquid paraffin,

dusting powder, fats and grease
42

Glass bead sterilization

Used to sterilize endodontic instruments
210c 230c for 10-30 sec.

43

Ethylene oxide, a gas at temperatures

above 108C, is a highly penetrative,
non corrosive agent with a cidal action
against bacteria, spores and viruses.

It destroys microorganisms by
alkylation; and causes denaturation of
nucleic acids
44

45

Uses:
Plastic

goods
polythene tube
artery and bone grafts
vaccines
culture media

46

Pasteurization

Used to kill bacteria in raw milk.

Holder Method 63 c for 30 mins

Flash Method -72c for 15 -20 sec

followed by quickly to 13c or lower

47

48

Hot Water Bath

To inactivate non sporing bacteria for the
preparation of vaccines - Special vaccine
bath at 60oC for one hour is used
Serum or body fluids containing coagulable
proteins can be sterilized by heating for 1 hr
at 56oC in a water bath for several
successive days.
49

50

Inspissator
Sterilizes by heating at 80-85oC for half an
hour for 3 successive days
Used to sterilize media such as LowensteinJensen & Loefllers serum

51

52

TEMPERATURE AT 100 OC
Boiling:
Kills vegetative forms of bacterial
pathogens.
Hepatitis virus: Can survive up to 30
minutes of boiling.
Endospores: Can survive up to 20 hours or
more of boiling

53

Disadvantage
Time

consuming
Does not destroy spores
Cutting instruments should not be
sterilized by boiling as they loose their
sharpness.

54

55

A single exposure of 90 min usually

ensures sterilization but for media
containing sugars or gelatin an exposure
of 100c for 20 min on 3 successive days
is used. This is known as
TYNDALLISATION or INTERMITTENT
STERILISATION.

56

Invented by Charles Chamberland in 1879

Autoclaves -2 types.
1.Porous load autoclave
2.Small bench top automatic autoclave
Temperature -136c;
Pressure-32pounds;
Cycle time-5min
flash sterilization.
57

 Denaturation

and coagulation of
microbial proteins occur during
exposure to the high temperature
of the steam.
Temperature: 121c
Pressure
: 15psi
Cycle time :15-20 min.
Packing material must allow
steam to penetrate
58

59

Advantages:

1. Short efficient cycle time.

2. Good penetration.
3. Ability to process a wide range of
materials.

60

Disadvantages
1.Corrosion of unprotected carbon steel.
2.Dulling of unprotected cutting edges.
3.Possibility that packages may remain wet at end
of cycle.
4.Possible deposits from use of hard water.
5.Possible destruction of heat sensitive materials.
61

This method uses a combination of dry

saturated steam and formaldehyde to
kill bacteria, spores and most viruses.

Formaldehyde acts by alkylation of the

nucleic acids

The required combinations of

temperature and pressure are 127 to
132C at 20 to 40 psi for 30 minutes.
62

63

For sterilization of :
Endoscopes
Cardiac

catheters

Respiratory equipment
64

Filtration :Filtration helps to remove bacteria from

heat
labile liquids such as sera and solutions of
Sugars or antibiotics used for preparation of
Culture media.

65

Following types of filters are used1.Candle filters- purification of water for

industrial and drinking purposes.
2.Asbestos filters Disposable, single use discs.
They have high adsorbing capacity
Alkalinize filtered liquids.

66

67

3.Sintered glass filters Are prepared by heat fusing finely

powdered glass particles of graded sizes.
low absorptive property
brittle and expensive.
4.Membrane filtersRoutinely used in water purification and
analysis,
sterilization and sterility testing
preparation of solutions for parenteral use.
68

Radiation
Two types of radiation are used for
sterilization.
1. Non ionizing and
2. Ionizing.
Non ionizing - Infra red and UV rays.
Ionizing

- Gamma rays and high energy

electrons.
69

Non Ionizing Radiation

Electromagnetic rays with longer

wavelengths are used.

Infra red radiation is considered as a form

of hot air sterilization.

70

USE
Rapid mass sterilization of pre packed
items such as syringes and catheters.

Disinfecting

enclosed areas such as

entryways, operation theatres and
laboratories.

71

Ionizing radiation

Also referred as cold sterilization

X- rays, gamma rays and cosmic rays are
highly lethal to DNA and other vital
constituents.
They have high penetrating power, since
there is no appreciable increase in
temperature.

72

USE
Commercial

plants use gamma radiation for

sterilizing items like plastics, syringes,
swabs, catheters, animal feeds, oils,
greases, fabrics etc.

73

Ultrasonic and sonic waves are credited

with bactericidal powers but the results
have been variable.
Microorganisms vary in sensitivity to them,
survivors are found even after treatment.
Hence it has no practical value in
sterilization and disinfection.

74

75

To be continued

76

Sterilization
and
disinfection
77

CONTENT
Chemical

agents
Classification of instrument to be sterilized
Test for sterilization
Disinfectants
Infection in dental operatory
Universal precaution
Patient preparation
Unit water line
Occupational accidental exposure management
Waste
Osha regulation
78

Chemical Agents

79

80

IDEAL CHEMICAL DISINFECTANT

Wide spectrum of activity

Active in the presence of organic matter

Effective in acid as well as alkaline media

Speedy action

High penetrating power

Stable

Compatible with other antiseptics and Disinfectants

Not corrode metals

81

Not cause local irritation or sensitization

Not interfere with healing

Not be toxic if absorbed into circulation

Cheap and easily available

Safe and easy to use

82

83

Alcohols
Ethanol

/Isopropyl alcohol are frequently

used
No action on spores
Concentration recommended 60-90% in
water

Uses
Disinfection

of clinical thermometer.
Disinfection of the skin

Spectrum: Effective against fungi, vegetative

bacteria, Mycobacterium species and some
lipid-containing viruses
84

Limitation: Not effective against

spores.
Concentration: Most effective at
70% in water.
Caution: Do not use near flames due
to flammability.
May swell rubber or harden
plastics.
85

Aldehydes
FORMALDEHYDE
To

preserve anatomical specimens

Destroying

Anthrax spores in hair and wool

10%

Formalin+0.5% Sodium tetra borate is used

to sterilise metal instruments

86

Formaldehyde gas
It is used for sterilizing instruments and heat
sensitive catheters, for fumigating wards, sick
rooms and labs.

Caution: Formaldehyde can react with free

. chlorine to produce toxic gas.
Irritant vapours are released hence

Neutralise with ammonia following

decontamination

87

FUMIGATION

88

Concentration: Glutaraldehyde is
commercially available as 2% w/v
aqueous solution which must be made
alkaline to "activate"

A 2% glutaraldehyde solution, for at

least 10 hours, can be used to
sterilize heat labile items.
Spectrum: Active against vegetative
bacteria, spores, fungi and many
viruses.

89

Use:

for instruments such as,

bronchoscopes,
corrugated rubber
anesthetic tubes, face
masks, endotracheal
tubes, metal instruments,
polythene tubing.

90

Caution:
Glutaraldehyde is known to cause dermatitis and asthma.
It should not be used in an area with

little or no ventilation.
Eye protection, a plastic apron, and gloves must be

worn
Should be stored away from heat sources and in

containers with close-fitting lids.

The length of time that glutaraldehyde solutions can

be used varies but they are usually good for up to 14

days.

91

Dyes

92

HALOGENS

93

Phenols
These

are obtained by distillation of coal tar

between temperatures of 170c and 270c
Powerful

microbicidal

Phenolic derivatives have been widely used as

disinfectants for various purposes in hospitals
Eg: Lysol, cresol

94

use :
To

clean wards

Various

combinations are used in the control of

pyogenic cocci in surgical & neonatal units in
hospitals.
Aqueous

solutions are used in treatment of

wounds

95

Metallic salts

Salts of silver, copper and mercury are used as

disinfectants.

Act by coagulating proteins

Marked bacteriostatic, weak bactericidal and

limited fungicidal activity

96

CLASSIFICATION OF INSTRUMENTS
TO BE STERILIZED

97

Semi critical
critical

Non critical

98

Improper cleaning of instruments

Improper packing
Improper temperature in sterilizer
Improper loading of sterilizer
Improper timing of sterilization cycle

99

Take the sterilizer out of service

Procedures to identify problems

Retest and observe the cycle

Determine the fate of sterilizer

Test the repaired or new sterilizer

100

Test for sterilization

Different micro-organism and chemical
indicators
are used for test .
Micro organism used :
Steam autoclave
Bacillus stearothermophilus vails
ampules or strips.

Dry heat oven

Bacillus subtilis strips.

Chemical vapour
Bacillus stearothermophilus strips.

Ethylene oxide
Bacillus subtilis strips

101

Commonly used disinfectants

Sodium hypochlorite (0.1- 0.5%)
Cidex(2% glutaraldehyde)
Chloramine 2%
Ethylalcohol [70% to 90%]
Formaldehyde 8% and Formalin 20%
Bisguanides.
Povidine iodine (2.5%)
Phenols
102

Broad spectrum of action

Fast acting.
Not affected by physical factors
Non toxic
Surface compatability
Should not have residual effect on treated
surfaces.
Easy to use.
Odourless
Economical
103

104

As a stop gap measure, to use only until the

sterilizable instruments can be obtained.

For use in surgical hand washing preparations

For disinfection of environmental surfaces

contacted during an appointment.

For disinfection of dental appliances prior to

insertion into a patients mouth.
105

Autogenous infections

Cross infections.

106

Are those caused by microbes that the patient

carries on or in his or her own body.

Many of the procedures in dentistry are invasive

and open the tissues to infections by micro
organisms. These microbes usually are harmless
within the oral cavity, but may cause disease if they
enter the tissues.
Eg: infective endocarditis, oral abscesses.

107

Many autogenous infections can be prevented by

preoperative prophylactic therapy.
Eg: endocarditis is prevented by the use of
antibiotics.

108

Are caused by infectious agents that are

transmitted among dental personnel, patient and
the environment.

The transfer of disease may be from dentist to

patient or vice versa.
Eg: hepatitis B is an occupational hazard for dental
personnel , on the other hand there are evidences
of dentists transmitting hepatitis B.

109

Patient to practitioner

Practitioner to patient

Patient to patient

Clinic to community

Clinic to practitioners family

Community to patient.
110

Blood and certain body fluids of all patients are

considered potentially infectious

Universal precautions include use of gloves,

gowns, aprons, masks, protective eye wear

Precautions to prevent injuries caused by needles,

scalpels and sharps

111

Clinical attire

Use of face mask

Gloves

Protective eye wear

112

Wearing apparel is vulnerable to contamination

from spatter, splash, aerosols and patient
contact
Gowns should be clean and maintained free
from contamination
High necked, long sleeved, knee length
Should be changed when visibly soiled
Disposable head caps should be worn to prevent
hair from contamination
Plastic or disposable apron
113

Surgical masks or chin length face shields must be

worn to protect face, oral mucosa and nasal
mucosa.

Masks should have 95% filtration efficiency of 3 to

5m in diameter

Should be changed for each patient

Chin length face shield may be worn

114

115

No contact with the wearers lips and nostrils

Has a high bacterial filtration efficiency rate
Fit snugly
No fogging of eye wear
Convenient
Made of material that does not irritate
Does not collapse during wear or when wet

116

Is necessary to prevent physical injuries and

infections of the eyes.

Contamination can be introduced from saliva,

biofilm, carious material, pieces of old restorative
materials during cavity prep, bacteria- laden
calculus during scaling and micro-organism in
aerosols or spatter.

Trans conjunctival transmission of hepatitis B

reported but rare.
117

118

Hands serve as a means of transmission of blood,

saliva, dental biofilm

Finger nails serve as a reservoir for microorganisms

Skin breaks serve as a port of entry.

119

Maintain clean, smoothly trimmed, short finger nails

Remove hand and wrist jewelry

Never expose open skin lesions or abrasions to

patients oral fluids or tissues

After glove removal, wash hands thoroughly

120

121

Wearing gloves is the standard practice to protect

both the patient and clinician from cross
contamination

Properly fitting gloves protect from exposure

through cuts and abrasions often found on hands.

122

123

Always glove and DE glove in front of patient

Place gloves over cuff of long sleeved clinic wear

Keep gloved hands away from face, hair, clothing,

telephones, pt records, clinicians stool etc

Immediately remove torn gloves, wash hands

thoroughly and don new gloves

Wash hands promptly after glove removal

124

Full mouth disinfection should be done.

It was introduced by Leuven et al in 1990.
should be completed in 2 appointments in 24 hrs
Scaling and root planing
Tongue is brushed with chlorhexidiene gel (1%) for 1
minute
The mouth is rinsed with chlorhexidiene
solution(0.2%) for 2 minutes
Periodontal pockets irrigated with chlorhexidiene
solution(1%)
125

126

Procedures for clinical use

Flush all water lines at least 2 min at the beginning

of each day.
Run water through water syringes for 30 seconds
before and after 30 seconds after each patient
appointment.

127

128

Significant exposure
Premucosal stick or wound with needle or sharp
instrument.
Contamination of any obviously open wound
with blood or saliva.
Exposure of patients body fluid to unbroken skin.

129

Procedure following Exposure

Immediately

wash the wound.

The

wound should be encouraged to bleed as

copiously as possible.
If

the patient has not received hepatitis B

vaccination this should be commenced
immediately.
In

some cases if hepatitis B positive then hyper

immune gamma globulin is given.
Many

authorities recommend the prophylactic use

of azothymidine for needle stick injuries.

130

WHO classified waste as :

1.General non hazardous
2.Sharp
3.Chemical and pharmaceutical
4.Infectious
5.Other hazardous medical waste

131

Colour

Types of waste

Red

Dressings, gloves & other

contaminated material

Yellow

Anatomical parts & lab waste,

biotechnology, microbiological
waste, blood , body fluids ,
bandages, soiled linen

Blue

Plastics, turbings, catheters, iv

sets, syringes without needles

white

Glass bottles and vials

Red can

Needles , scalpels, surgical

132

133

Osha Regulation
1.Employers must provide HB immunization to employees
without charge within 10 days of employment.
2. Employers must require that universal precautions be
observed
3. Employers must implement engineering skills to reduce
production of contaminated spatter, aerosols
4.Employers must implement work practice control
precaution to minimise splashing spatter or contact of
bare hands with contaminated surfaces
5. Employers must provide facilities and instruments for
washing hands, removing gloves and washing other skin
surfaces as soon as possible after contact with blood
134

6. Employers must prescribe safe handling of needles and

other sharps
7.Employers must prescribe disposal of single use needles,
vials and carpules
8.Contaminated reusables must not be stored or processed in
a manner that requires employees to reach hands into
containers to retrieve them
9.Employers must prohibit eating, drinking in the operatory or
clean up area.
10.Place blood and contaminated specimen into suitable
containers
135

11. At no cost to employees, employers must provide

personal protective equipment
12.Contaminated equipment that requires service must first
be decontaminated
13. Contaminated sharps and regulated wastes should be
discarded in hard walled containers
14.Employers must provide laundering of protective
garments

136

Text book of microbiology

Ananthnarayana & Paniker 7th edition
Medical microbiology greenwood
Clinical practices of dental hygenist
Wilkins 9th edition
Contemporary oral and maxillofacial
surgery Peterson 2nd edition
Text book of oral and maxillofacial surgery

Gustav O. Kruger -6th edition

137