STERILIZATION AND ASEPSIS IN MINOR ORAL SURGERY

PRESENTATION BY DEEPTHA.J

WHAT IS STERILIZATION ?
STERILIZATION : It is defined as the process by which an article, surface and medium is freed of all microorganisms either in vegetative or spore state. Patterson 1932: a process by which all microbial forms are destroyed.

WHAT IS DISINFECTION?
Means destruction of all pathogenic microorganisms, or organisms capable of giving raise to infection.

WHY STERILIZATION ?
According to the GERM THEORY OF DISEASE, micro-organisms are cause for infectious disease Since the days of PASTEUR, thousands of pathogenic or disease causing micro-organisms have been identified. BACTERIA, FUNGI, VIRUS, PROTOZOA are examples of harmful micro-organisms.

WHY STERILIZATION ? contd

To avoid introducing new micro-organisms in surgical field pathogenic micro-organisms introduced into wound blood stream wound breakdown delayed healing To prevent cross-contamination

WHY STERILIZATION ? contd

Patient

Operator

Other personnel

CHAIN OF INFECTION
(sufficient virulence & adequate numbers)

Pathogen

Susceptible Host

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

(allows pathogen to survive & multiply)

Source

Entry

Mode
(of transmission from source to host)

WHY STERILIZATION contd

VIRAL
INFECTIOUS DISEASE
-HIV [ AIDS ] - HEPATITIS - HERPES Innoculation - PAPILLOMA - MUMPS, MEASLES, RUBEOLA - Inhalation
TUBERCULOSIS- Inhalation

BACTERIA

FUNGI

( THRO INFECTED AEROSOLS) -CORNEBACTERIUM -TREPONEMA - CANDIDA

- PNEUMOCYSTITIS CARNII

- LEGIONNERES DISEASE

NEED FOR STERILIZATION

HEPATITIS A,B,C,D,E,F,G. Vaccination against hbv only available !!!
Broad spectrum antibiotics- unjustified security PROTECT YOURSELF!! HENCE STERILIZATION IS THE ONLY SIMPLE COST EFFECTIVE WAY TO REDUCE MICROBIAL LOAD.

HOW TO STERILIZE ?

Cannot autoclave patients

CLASSIFICATION OF VARIOUS STERILIZATION AGENTS

A) Physical agents 1) Sunlight 2) Drying 3) Dry heat : Flaming Incineration Hot air 4) Moist heat : Pasteurization Boiling Steam under normal pressure Steam under pressure 5) Filtration : Candles Asbestos pads Membranes 6) Radiation : ultra violet radiation Ionizing radiation 7) Ultrasonic and sonic vibrations

B) Chemicals 1. Alcohols : Ethyl, isopropyl, methyl. 2. Aldehydes : Formaldehyde Glutaraldehyde 3. 4. 5. 6. 7. 8. Dyes Halogens Phenols Surface active agents Metallic salts Gases : Ethylene oxide, formaldehyde, beta propiolactone

CAN INSTRUMENTS GO STRAIGHT INTO THE STERILIZER ?

Pre soaking of instruments.

Pre sterilization cleaning

-manual -ultrasonic Packaging
journal of dental practice-vol5-mar06

(HOLDING/PRESOAKING)
Keeps instruments wet.

Prevents drying of saliva &blood on the instruments. - Lawrence & Block 1968 Facilitating easy cleaning.
solution used may be phenol or glutaraldehyde. Not more than few hours-corrosion

PRE-CLEANING
1. Ultrasonic processing 2. Manual cleaning

Advantage of Ultrasonic processing

Manual cleansing

Increased efficiency in obtaining a high degree of cleanliness. Reduced danger to clinician from direct contact with potential pathogenic microorganisms. Improved effectiveness for disinfection Elimination of possible dissemination of microorganisms through release of aerosols and droplets, which can occur during scrubbing process. Penetration into areas of the instruments where the bristles of a brush may be unable to contact. Removal of tarnish. Ultrasonic processing is the method of choice, but when manual cleaning is the only alternative, precaution must be taken to prevent contamination

PACKING
Prevents post- sterilization contamination Packing material : A single layer cloth wrap - steam sterilization , self sealing polyfilm pouches- chemical vapour sterilization, paper wrap-dry heat sterilization. Tested by placing spore strips inside the material and then processed thro sterilizer, ensuring that the spores are killed.

SPAULDINGS CLASSIFICATION
Who Was Spaulding? In the mid-1960s Dr. Earl Spaulding developed a framework for sterilization. The system is based on the patient's risk for infection that various types of instrument or equipment contact can create.

CLASSIFICATION OF INSTRUMENT STERILIZATION -CDC

The categorization of instrument depends on the contact with different tissue types to determine whether sterilization / disinfection is required. The categories are as follows. 1. Critical items : Instrument that touches sterile areas of the body enter the vascular system and those that penetrates the oral mucosa. Eg : scalpel, curettes, burs 2. Semi critical items : Instrument that touches mucous membrane and oral fluids but do not penetrate tissue, Eg.: saliva ejectors, radiograph, bite blocks, mouth mirrors etc. 3. Non critical items : Those items that does not come in contact with oral mucosa but are touched by saliva / blood contaminated hands while treating patient. Eg.: Chair light, switches, drawer pills etc.

STERILIZATION CYCLE
The time required to achieve sterilization is referred to as process cycle, which includes
Heat up &/or penetration of the agent Kill time Safety factor for bioburden Evacuation or dissipation of the agent

SUNLIGHT
Sunlight possess appreciable BACTERICIDAL activity ( kills HIV virus in 3-4 mins) It is the sterilization which occurs at normal condition The action is due to the content of uv rays and heat
Simple and Grieg showed that, in India, typhoid bacilli exposed to the sun on pieces of white drill cloth were killed in two hours, whereas controls kept in the dark were still alive after six days. Bacteria suspended in water are readily destroyed by exposure to sunlight.

DRYING
Moisture is essential for the growth of bacteria. Four-fifth by weight of the bacterial cell consists of water. Drying in air has therefore, a deleterious effect on many bacteria. This method is unreliable and is only of theoretical interest. spores are unaffected by drying.

HEAT
Heat is dependable physical agent for destruction of all forms of microbial life, including spores. Moist heat is more effective than dry heat.

The killing effect of dry heat is due to protein denaturation, Oxidative damage & toxic effect of elevated levels of electrolytes. Moist heat kills microorganisms by Coagulation and denaturing their enzymes and structural proteins, a process in which water participates.

HEAT-contd
Moist heat is effective at lower temperature. A properly designed autoclave will effectively sterilize media and other water containing materials in sealed or unsealed bottles, laboratory discards and porous packaged materials.

Dry heat is suitable for oils, petroleum products ,oily injections talc, glasswares,beakers,flasks Dry heat cannot be used for water containing culture media.

DRY HEAT
a) FLAMING / RED HEAT
b) INCINERATION

c) HOT AIR OVEN

.

 Advantages of dry heat More convenient Instruments are less likely to corrode ( dry heat is a protective type of sterilization ) Do not require drying after sterilization. Disadvantages of using dry heat Much harder to kill than when they are wet. Has very little power of penetration and unless very high temperatures are used, the method is slow. Instruments need a considerable time to cool after sterilization and the temper of metal instruments may be lost

Rate of microbial death

When bacterial populations are heated or treated with antimicrobial chemicals, they usually die at a constant rate.

HOT AIR OVEN

PARTS Fan Temperature indicator, Control thermostat, Timer, Open mesh shelving Wall insulation.

The oven is usually treated by electricity, with heating elements in the wall of the chamber. Door interlocks is fitted to ensure the heating cycle will not start until the door is shut and that the door will not open while the cycle is in progress. Arrangement of instruments should allow free circulation of air

TIME TEMPERATURE FOR HOT AIR OVEN

Sterilization is achieved by dry heat at

160C for 60 minutes, 170C for 15 minutes, 180C for 7 minutes, 190C for 1 minutes

PRECAUTIONS TO BE OBSERVED IN HOT AIR OVEN

Temp should not be greater than 180c. The glassware - dry No sudden cooling No over loading Free circulation of air.

FLAMING
The articles are passed on the Bunsen flame.

Articles Sterilized:

Inoculating loop of wires. Forceps. Spatulas. Mouths of culture tubes.

All these articles are made red hot by placing them over the Bunsen flame but articles like cover slips & glass slides which are fragile are passed between the Bunsen flame for a few seconds & they are never made red hot.

INCINERATION
Contaminated material in bulk is sterilized & disposed by burning in an incinator. Articles sterilized: All surgical dressings Used disposable syringes All contaminated lab materials Animal carcass Bedding.

MOIST HEAT
Moist heat can be employed
At temperature below 100C
At a temperature of 100C (either in boiling water / in free steam) At a temperature above 100C (in saturated steam under increased pressure).

MOIST HEAT -Temperature below 100C:

(a) Pasteurization of Milk: There are 3 types of methods. Holders process Temp. is 65c for 30min Flash process Temp. 72c for 15-20 sec & sudden cooling to 13c Ultra pasteurization- temp 82c 3 secs & sudden cooloing (b) Vaccines of non-sporing bacteria: They are heat inactivated by placing it in special vaccine bags, which is maintained at 60c for one hour.
(c) To sterilize serum: body fluids which contain coagulable proteins (egg yolk, synovial fluid) sterilized by placing them in a water bath at 56c for 1 hour for several successive days.

CONTD
(d) Certain instruments: Like spatula, cytoscopes, & other instruments that can be damaged by excess of heat can be sterilized by keeping them in water bath at 75c for 10 minutes. (e) Certain media: Such as Lowensteins Jensens media which contains egg & other media which contain sugar & gelatin by placing it in an Inspissator which is maintained at 80-85c for an hour on 3 successive days.

(f) Bed cloths & certain utensils used patients by can be sterilized by placing them at 75c-80c for several minutes temp to ensure complete sterilization.

TEMPERATURE AT 100C
NOT a preferred method of sterilization. Vegetative forms are killed in few minutes at 54 to 65oC. Certain bacterial spores will withstand 115oC for 3 hours!

(a)Boiling:

Boiling can destroy most of the non- sporing bacteria but for complete destruction it should be boiled for considerable period (10-15mts).

Effective boiling is brought about by adding 2% sodium bicarbonate solution which will promote sterilization. Certain metallic instruments & glassware can be sterilized by boiling.

CONTD
(b) Kochs & Arnolds steam sterilizer: This apparatus consists of copper
lined cabinet with perforated tray & a conical lid, which has slight opening, which allows steam to pass out. Works by gas or electricity. It is used for single exposure sterilization. Articles are kept at 100c for 90 minutes.

Culture media sterilization

TYNDALLISATION
Sterilization through intermittent exposure known as tyndallisation. It was discovered by Tindal. Temp is 100c for 20 min on 3 successive days. Advantages: During the 1st exposure all vegetative bacteria present in the media is killed during the next 24 hours the spores that are present in the media germinate. During 2nd exposure all the germinated bacteria will be destroyed. During 3rd exposure complete sterilization is ensured.

It is mainly used to sterilize culture, media which contains sugar & gelatin.

TEMPERATURE ABOVE 100C

- Von Bremann
AUTOCLAVES
Principle: Direct saturated steam contact is the basis of steam sterilization. when steam comes in contact with cooler surface, it condenses into water and gives of latent heat to that surface. The condensed water ensures moist conditions for killing microbes. Pressure increases the boiling temperature but it itself does not have any effect on micro-org or steam penetration

TYPES
I. laboratory AUTOCLAVES, II. hospital dressing sterilizers, III. rapid cooling sterilizer I. HORIZONTAL II. VERTICAL

I.

N-CYCLE (gravity displacement/non vacuum/downward displacement ) II. B-CYCLE ( pre vacuum ) III. S-CYCLE( high speed pressure ) TEMPERATURE : 121c-15lbs-15 mins 126c-10 mins 134c-30lbs-3 mins

DOWNWARD DISPLACEMENT STERILIZER

Air is heavier than steam Steam forces air out Valve closes CRITICAL ISSUES: CAREFUL WRAPPING! CAREFUL LOADING!

Heat between 121 to 134 degrees centigrade 15 minutes @ 121 C 3 minutes @ 134 C

B CYCLE & S CYCLE

PRE-VACUUM STERILIZATION More rapid and efficient steam penetration Pulls air (out) -- vacuum When the wrapper if carefully opened, it provides a sterile surface for the instruments during the surgical procedure. PRESSURISED STEAM STERILIZATION S CYCLE

FLASH STERILIZATION is performed either thro gravity displacement type or pre vacuum type non-sterile item needs to be sterilized quickly. Item is placed unwrapped in a perforated metal tray and sterilized according to the manufacturers time and temperature recommendations. The sterilized items are transported to the OR in the metal tray. Difficult to deliver flash-sterilized devices aseptically (tray is hot, wet and instruments are unwrapped

AUTOCLAVE
Small Sterilizers Cycle type N-cycle B-cycle solid/hollow multiwrapped/nonwrapped porous S-cycle (Statim) solid/hollow wrapped/nonwrapped Materials that solid only can be sterilized non-wrapped only

Air removal

<P<GRAVITYforced DISPLACEMENT< p> 25 minutes 45 minutes

pressure pulsed

6-9 minutes

AUTOCLAVE
Articles sterilized: Surgical Instrument- forceps,etc Surgical Cotton All culture media except media contain sugar & gelatin. Lab coats, rubber gloves Test tubes, enamel metal trays, Handpieces ,steel burs,tongue depressors

Advantages Easiest, safest, surest Fastest Least expensive Automatic Many items withstand repeated processing Leaves no harmful residue

 Disadvantages

AUTOCLAVE

Preparation and package to be careful Item must be clean and free from grease and oil Steam must have direct contact with all areas of an item Timing depends on material and load chance of human error Impurities in water (steam)

No living things can survive saturated steam at 121oC longer than 15 minutes. All vegetative forms are killed at 54-65c Spores can withstand 115c for more than 3 hrs

RADIATION
It is brought about by 2 methods. Ionizing radiation particles gamma rays Non Ionizing radiation uv rays infra red microwaves

IONISING RADIATION

E.g. X- rays gamma rays, cosmic rays. COLD STERILIZATION.

MECHANISM : ionic energy- thermal & chemical energy- dna affected. Articles sterilized: Any type of plastic disposable syringes, catheters, all glass materials, animal feeds, cloths oils, grease, rubber material.

NON-IONISING RADIATION
U V RAYS & INFRARED RAYS Also called hot sterilization MECHANISM: It produces hyperthermic conditions that disrupts life Heat affects water molecules and interferes with cell membranes

U. V. rays: they are used to bring down the number of microorganism present in air. So it is used for sterilization of Operation Theater and also biological safety cabinets used in the laboratory. Dis adv: Low-penetrating power.

INFRA RED RADIATION:

The temp attained is 180c and it is kept for 7- min. Article sterilized: Certain metallic instruments Glassware. This is usually employed in central sterile supplying department (CSSD) in Certain hospitals.

FILTRATION
This is used to sterilize heat labile liquid or all those liquids which are affected by increase in temp can be sterilized. E.g. Serum antibiotic culture & sensitivity media containing sugars & gelatin.

IT IS BROUGHT ABOUT BY
Candles filters
Unglazed ceramic filters. Diatomaceous earth filters.

Asbestos disc filters. Sintered glass filters Membrane filters.

These filters are sterilized by autoclaving at 121c for 15 minutes.

1) Candle filters:
USES:

For purification of water. Preparation of antibiotics, sera

Unglazed ceramic filters: after use can be cleaned with sodium hypochlorite solution. E.g. chamber land & doulton filters. Diatomaceous earth: This can be cleaned with hypochlorite solution E.g. Berkefeld & Mandler filters.
Advantage:

Handle large amount of contaminants

Retain particles smaller than their normal size rating because absorption of particles on the filter
Disadvantages:

of

Media migration contaminate the product.

Release of microorganisms during long process times Retain significant amount of fluid products.

2) Asbestos Disc filters:

are disposable, single use discs. They have high adsorbing capacity Disadvantages Tend to alkalinize filtered liquids. Carcinogenic potential of asbestos has discouraged their use. E.g. Seitz, carbon & sterimat filters.

3) Sintered glass filters:

Prepared by heat fusing finely powdered glass particles of graded sizes Low absorptive property. Can be cleaned easily Are brittle & expensive

4) Membrane filters:
Made up of cellulose filters or polymers used in water purification & analysis, sterilization ,sterility testing and preparation of solutions for parenteral use. APD- 0.22 m or less size most widely used. Advantages: Do not contaminate the product during media migration No release of microorganisms during long process times Do not retain the fluid products.

Disadvantages: Tend to get stopped up by excess dirt in the system.

SONIC AND ULTRASONIC

Bactericidal But the results are variable hence no practical significance

Test for efficiency:

Mechanical indicators thermocouple thermometers Chemical indicators browns tube autoclave tape Biological indicators Bacillus steatothermophilus 55-60c Bacillus subtilis 35-37c Clostidium tetani 121C

CHEMICAL METHOD
It is carried out by inserting a Browns tube inside the hot air oven, which develop green spots at 160c after 1 hr. Autoclave tape contains a sensitive ink that undergoes color change at specific temp -forms the basis of bowie-dick test for high vacuum autoclaves
TST strips

BIOLOGICAL METHOD
Clostidium tetani on a filter paper strip and place it inside the hot air oven for 160c for 1hour . The filter paper strip is inoculated into thioglycolate media & incubated aneorobically at 37c for 5 days. If the spores germinate it indicates hot air oven is not working efficiently. Spores of bacillus steatothermophilus for moist heat sterilization

RELIABILITY PARAMETERS FOR STERILIZATION

PRODUCT ASSOCIATED PARAMETERS - Bioburden - Bioresistance - Biostate - Bioshielding - Density PROCESS ASSOCIATED PARAMETERS - Temperature - Humidity/moisture/hydration - Time - Purity of agent & air - Saturation/penetration - Capacity of the sterilizer & position of items within sterilizer

CHEMICAL DISINFECTANTS

Alcohols, Aldehydes, Biguanides, Halogens, Phenolics, Quaternary Ammonium Compounds

BACTEIOSTATIC & BACTERIOCIDAL AGENTS

These are the agents, which inhibit the growth of bacteria
These agents, which kill the bacteria.

DISIFECTANTS & ANTISEPTICS

(Patterson 1932): A chemical used on nonvital objects to kill surface vegetative pathogenic organisms but not necessarily spore forms or viruses. A chemical that is applied to living tissues such as skin or mucous membrane to reduce the number of microorganisms present through inhibition of their activity or destruction.

HOW TO DISINFECTANTS ACT?

1) Protein coagulation. 2) Disruption of cell membrane. 3) Removal of free sulphydryl groups.

4) Substrate competition.

CHEMICAL DISINFECTANTS
Effective agent to sterilize items which are destroyed by heat.
CENTERS FOR DISEASE CONTROL AND PREVENTION- CLASSIFICATION - HIGH LEVEL DISINFECTANT : For killing all micro-org on

submerged inanimate objects that are heat sensitive e.g Glutaraldehyde - INTERMEDIATE LEVEL DISINFECTANTS : For killing vegetative bacteria, most fungi, viruses and m. Tuberculosis e.g Iodophors - LOW LEVEL DISINFECTANTS : For killing most vegetative bacteria, some fungi, and some viruses e.g quaternary ammonium compounds

ALCOHOLS
Isopropyl alcohol & 70% ethyl alcohol & methyl alcohol
VIRUCIDAL ( BUT NOT LIPID VIRUS), FUNGICIDAL,AGAINST MYCOBACTERIUM TUBERCULOSIS

Alcohols do not solubilise protein material in blood or saliva and hence they are poor cleaners.

They dry out skin because tend to dissolve fat and oil that serves as natural skin moisteners

ALCOHOLS
USES EG. DETTOL- SKIN DISINFECTANTS TIME: 10-30 MINS Iso propyl alcohol- disinfect clinical thermometers. Less volatile Ethyl alcohol- Suitable for skin preparation before venepuncture. It is highly volatile Methyl alcohol-to disinfect safety cabinets and incubators. Fungicidal

Aldehydes
Glutaraldehyde (Cidex 2%), & Formaldehyde (formalin 37%) Active against G-ve bact., spores, viruses (HB, HIV) & fungi Require 3 hours of exposure

Suitable for non autoclavable instruments

Blood/saliva spillages

GLUTARALDEHYDE
2.4 %, 2.5%, 3.4% aqueous solution Half life of cidex- 14 days cidex 7- 28 days Alkaline Glutaraldehyde changes ph rapidly and loses its effectiveness after the date of expiration. Therefore the expiry date has to be marked when activated For instruments which are destroyed by heat Bactericidal, pseudomonacidal, Fungicidal and Virucidal in 10 minutes. Tuberculocidal in 45 minutes. Sporicidal in 10 hours. ( becomes a sterilant )
Disinfection only !

GLUTARALDEHYDE
ADVANTAGES Non-corrosive Low surface tension. Not absorbed by rubber or plastics. Low volatility. Active at room temperature
DISADVANTAGES Buffer to be added for activation. Gradually loses effectiveness. May cause skin irritation. Mild odour.

Biguanides
Chlorhexidine 2-4%- PIN CUSHION EFFECT
Active against Staph. aureus & some G-Ve bacteria Active against fungi & viruses ONLY at very high conc Inactivated by soap and pus Ototoxicity if instilled into the middle ear
0.2%

Antiseptic: Used for disinfecting skin and mucous membranes e.g.:

Savlon: 0.5%CHX + Cetrimide Hibiscrub: 4%CHX + detergent Hexana, Corsodyl mw =0.2% CHX

 Chlorhexidine gluconate has been shown to be effective against all microorganisms including Staphylococcus aureus. However, it does not have as wide a spectrum of antiviral activity as povidoneiodine. Chlorhexidine use creates a protective bacteriostatic film on the skin that maintains a high level of activity against gram-positive organisms. Chlorhexidine has been reported to cause sensorineural deafness when it enters the middle ear. There have been a few reported cases of irreversible corneal eye damage caused by eye contact during facial skin preparation before surgery

HALOGENS-CHLORINE

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

Sodium hypochlorite, 10000 ppm of available chlorine Commercial bleach 5.25% sodium hypochlorite 1:10 to 1:100 dilution Active against bacteria, spores, fungi and viruses (HB, HIV) 20 minutes of exposure time Inactivated by blood, pus and dilution

HALOGENS-IODINE
Iodine alcohol mixtures ( tinctures of iodine ) Iodine complexed with organic materials- iodophor Iodophors & tinctures
Active against bacteria, spores & some viruses & fungi Can be inactivated by pus and blood USES Suitable for skin preparation, mouthwash & as a surgical scrub (7.5% Povidone-iodine= Betadine)

HALOGEN-IODINE
Aqueous alcoholic solution can be used as skin & wound antiseptic. It is bactericidal & veridical. Strong iodine 19% weight / volume of iodine. Weak iodine solution 2% weight / volume of iodine. Betadine 12% weight / volume.- iodine sensitivity Uses - hand washes -Preoperative skin -Preparation Sterilization of surgical instruments. Iodoform (white head varnish) Bismuth Iodoform Paste used in dressing of -Dry socket -cyst cavity -Bony defects.

betadine
The most potent agents to inactivate PVP-I include free sulfur-containing amino acids, such as cysteine and methionine Patients are typically prepared with a scrubbing solution of 7.5% PVP-I applied in circular motion outward from the center of the surgical site, followed with a blotting or rinse, and covered with a paint of a 10% PVP-I solution. Betadine scrub contains surfactant which reduces the surface tension and increases the antimicrobial activity

 Both gram-positive and gram-negative organisms are sensitive Povidone-iodine acts on a wide variety of bacteria (including anaerobic and sporulated organisms), fungi, protozoa, and viruses. Systemic toxicity in a group of burn patients with more than 25% of the total body surface area burned has been reported. Refractory metabolic acidosis and acute renal failure occurred in this group and a few died.8,9 In newborns exposed repeatedly to povidone-iodine for skin and umbilical cord cleansing, cutaneous absorption may lead to hypothyroidism, which may be detrimental because thyroid hormones are critical to brain development

Betadine vs chlorhexidine
Iodophore G+,G-,fungi, virus Scrub 7.5% with surfactant paint 10% Irrigation 5% Biguanide G+, some G- & fungi and virus in very high concentrations Scrub 4% iodine toxicity, hypothyroidism savlon 0.5% chX + cetrimide in neonates plain 0.2%
Sensoneural deafness in middle ear

HEAVY METALS
Include copper, selenium, mercury, silver, and zinc. OLIGODYNAMIC action: Very tiny amounts are effective. MERCURY mercurochrome are used to disinfect skin wounds. mercuric chloride is strong fungicide SILVER 1% silver nitrate solution is used for the treatment of dry socket & used to relief of pain, stimulates granulamatous tissues. COPPER Copper sulfate is used to kill algae in pools and fish tanks. Copper salts are used as fungicides. SELENIUM Kills fungi and their spores. Used for fungal infections. Also used in dandruff shampoos. ZINC Zinc chloride is used in mouthwashes. Zinc oxide is used as antifungal agent in paints.

Phenolics
Also known as carbolic acid Joseph lister used phenol as antiseptic Synthetic phenols- intermediate level disinfectant Hexachlorophenes Active against staph aureus, limited activity against G-ve bacilli Uses: Surgical scrub 2% phenol (Phisomed) House keeping disinfectant

Quaternary Ammonium Compounds

Types : Alcohol free quats (Low level disinfectant; non tuberculocidal) Quats with alcohol ( intermediate level disinfectant ;tuberculocidal) Cetrimide (+0.5%CHX= Savlon) Active against staph aureus Easily inactivated by water and soap Can be contaminated by pseudomonas

Benzalkonium chloride
It is one of the most aqueous quaternary ammonium compounds and is used both as an antiseptic and as a disinfectant.

According to neugeboren and co-workers its antibacterial spectrum is similar to the alcohols being limited largely to gram-positive microorganisms and some gram-negative organisms. It is not effective against spores, viruses and mycobacterium tuberculosis.

Hotchkiss 1946 noted that this molecule is a strong surfactant that increases the permeability of the bacterial well and permits the escape of phosphorus and nitrogen. It also denatures intracellular protein.

Gaseous disinfectants:
Formaldehyde Ethylene oxide Beta propriolactone (BPL)

FORMALDEHYDE
It is used in fumigation of operation theatres, laboratories, to sterile books, cloths, furniture etc.
Formaldehyde not popular because of its noxious odors

Drawback: Since it is irritant & toxic the room should not opened for at least 48 hours.

ETHYLENE OXIDE
It is a colorless liquid with boiling point 10.7c. At normal temperature and pressure, it is a gas, which have very high penetration power. It can be used to sterilize any porous material. 12/88- 12% EO 88% CFC 10/90 10% EO 90% CO2 Temperatures- 29-63c

ADVANTAGES

Effective substitute Automatic controls preclude human errors EO leaves no film on items

ETHYLENE OXIDE
Suitable for working surfaces & instruments It is viricidal, sporicidal & bactericidal. 14-18 hrs

Drawbacks: It is highly toxic mutagenic,

carcinogenic & highly inflammable.

Limitations:

The object to be disinfected must be thoroughly cleaned Efficient at certain Concentration & Temperature Each agent needs a certain minimum exposure time Certain chemicals may damage certain surfaces Shelf-life Complicated process requires monitoring Toxic by- products are formed Expensive

BETA PROPIOLACTONE
It has got lower penetration power. It is condensation product of ketone & formaldehyde. It is carcinogenic 0.2% betapropiolactone is used for sterilization of certain vaccines. It is virucidal & bactericidal. It is used for sterilization of rabies vaccines.

D. Coal Tar derivatives: Phenol 5-10% Lysol 2.5% disinfectants Cresol 2.5-5% Chlorhexidine antiseptics Hexachlorophene ( neurotoxic )

E. Dyes: It is used as skin & Wound disinfectant. High dilution-bacteriostatic & low bacteriocidal Impair DNA complexes & thus kill or destroy the reproductive capacity It is divided into 2 groups. Aniline dyes Eg : brilliant green, malachite green, crystal violet Active against gram +ve No activity against tubercle bacilli and hence used in Lowenstein jensen medium Lethal effects are due to acid groups Acridine dyes: Proflavine , acriflavine, euflavine & aminacrine

 F. Surface active agents: These are the substances which act at energy relationship at interfaces producing a reduction of surface or interfacial tension. They are detergents, wetting agents & soaps. Soaps saturated fatty acids(coconut oil) effective against gram ve bacilli. Soaps unsaturated fatty acids(olic acids) effective against gram +ve bacteria.

Efficiency of various disinfectants

RECENT ADVANCES ? ?

HYDROGEN PEROXIDE PLASMA STERILIZATION H2O2 activation Reactive plasma Plasma 4th state of matter Produced by strong electrical and magnetic field Plasma cloud contains ions, electrons & neutral atomic particles that produce a pink glow MECHANISM : Free radicals from the cloud interact with cell membranes, enzymes, nucleic acids and disrupts vital functions They are highly sporicidal at low concentrations Used for metallic or non metallic instruments

Ozone gas sterilization

ozone sterilizes by oxidation that destroys organic and inorganic matter. Penetrates membrane of cells causing them to explode. Low temperature method of sterilization ADVANTAGES : Simple and inexpensive Alternative to gas sterilization Leaves no residue Does not affect ti,cr,si & teflon DISADVANTAGE : Oxidises steel, iron, brass, aluminium Destroys natural rubber

 Test for disinfectants: It is used determining the quality of the disinfectant. Rideal Walker test: Test is used to estimate the efficacy of a disinfectant. The highest dilution of the given disinfectant that kills bacteria, divided by the highest dilution of phenol that sterilizes the solution, within the measured time Chick Martin Test: Modified rideal test Here the disinfectant acts in presence of organic matter ( dried yeast of feces )

STERILIZATION OF HIV INFECTED ARTICLES

Autoclaving at 1210c ,15lbs pressure for 20 minutes. Dry heat-1600 c for 1 hour. Boiling for 20-30 minutes. CHEMICAL DISINFECTANTS Sodium hypochlorite - 5 gm/lit Calcium hypochlorite - 1.4gm/lit Chloramine - 70gm/lit Ethanol - 70% Formalin - 3-4% REUSABLE INSTRUMENTS Non autoclavable instruments should be immersed in 2% Glutaraldehyde solution for 1 hour. The instruments are cleaned with warm water and detergent. They are rinsed left soak in 2% glutaraldehyde for 3 hours.

STERILIZATION OF HEPATITIS INFECTED ARTICLES

Hepatitis B virus remains viable at room temperature for at least 1 month
Steam autoclave 10 min exposure to 1:100 diluted bleach 1:16 diluted phenolic glutaraldehyde 75ppm iodophor 70% isopropyl alcohol HBV is easy to kill when outside the body, provided the killing agent comes in direct contact with the virus. HBV is more easily killed than mycobacterium tuberculosis and bacterial spores

TUBERCULOSIS
The risk of dental team acquiring TB is very low because prolonged exposure to an infectious environment is necessary & brief contact appears to of little risk. Respiratory aerosols remain airborne for several hours Dentists should not treat patients with active TB

CONCLUSION

REFERENCES
Textbook of microbiologyAnanthanarayan Berry & kohns operating room technique Infection control procedures- baker Textbook of oral & maxillofacial surgery-neelima anil malik Art & science of operative dentistry sturdevant

Preferred methods of sterilization for common use articles

Autoclaving Animal cages Sugar tubes Lab coats Cotton Hot air oven Glass ware Beakers Flasks Petridish Ethylene oxide Glutaraladehy de Fabric Bedding Blanket Clothing Endoscope Cystoscope Filtration Antibiotics Serum Vaccines

Filters
Instruments Culture media

Pipette
Slides Syringes

Mattresses
Pillows Disposable instruments

Rubber Gloves Stopper Tubing

Test tubes Glycerin Needles Oils

Blades Knives Scalpels Scissors