CONTENTS INTRODUCTION PAST CONCERN DEFNITION CLASSIFICATION OF INSTRUMENTS TO BE STERILIZED BEFORE STERILIZATION RATE OF KILLING PRINCIPLES OF STERILIZATION AFTER

N AFTER STERILIZATION DISINFECTION IN ENDODONTIC PRACTICE ADVANCES REFERENCES CONCLUSION

I. INTRODUCTION :

Microorganisms are present all around us may be in active. Suppressive from since they cause contamination, infection and decay. H became necessary to remove or destroy them from the materials or the related areas. So this is the main objective of sterilization. In our daily routine practice we are paying very less attention towards sterilization and disinfection as a result of which treatment provided to the patient can be a failure. So in a country like India with a huge population and demand for health service it is important to follow strict sterilization and disinfection procedures in dentistry to prevent spread of infections.

II. DEFINITION : Sterilization is a process by which actives surface or medium are freed of all microorganisms of both in vegetative or spore state. Disinfection : resistant spores. !ntiseptic " #hemical disinfectant which are safely applied to the skin or mucous membrane and used to prevent infection. Disinfect nt : $eserved % &r. germicides which are too corrosive or to'ic to be applied on tissues but which are suitable for application on objects or articles by inhibitions the growth. estruction of pathogenic organism but not necessarily

III. CLASSIFICATION OF INSTRUMENTS TO BE STERILIZED :

A!

CRITICAL : Surgical and other instruments used to penetrate soft tissue and bone. eg" Surgical burs, elevators forceps, scalpel scaling instruments sutures, needles.

B!

SEMI CRITICAL : Instruments that do not penetrate soft tissue or bone but contact oral tissue. (g" mirror, amalgam carries, plastic instruments tweezer.

C!

NON CRITICAL : o not come in contact with body fluids. (g" medicament tars, cavity liners, restorative material light switches, drawer pulls on cabinets.

IV. PROCEDURE BEFORE STERILIZATION : )* +* -* &rouping and presoaking of contaminated instruments. ,re sterilization cleaning. ,acking and sealing of instruments. &rouping and presoaking of contaminated instruments. Instruments should be grouped according to their use, .eg" amalgam set, composite set* banded together and presoaked together. ,resoaking prevents blood to adverse into instrument surface and easily removed by cleaning process. / cleaning. ,re sterilization cleaning !fter soaking, instruments should be cleaned.

#leaning is performed by scrubbing with soap and H +0 or ultrasonic

,acking and sealing of instruments. Instruments should be properly packed and before sterilization

packing protects the instruments after sterilization and before use at chair side. ,acking materials used are sealing paper, plastic pouches, bags and tubing. Selection of packaging materials for various sterilization methods " P c" #in# $ te%i & ,aper, plastic pouches paper thin cloth, nylon type 1ylon plastic tubes some sterilization paper. ,lastic pouches of some sterilization paper.

Moist heat ry heat #hemiclave

V. R te of "i&&in# of $ic%oo%# nis$s : $ate of killing is defined by relationship. 1 ) #2

1 no. of survivors is inversely proportional to the conc. and time of the sterilizing agent. P'(sic & #ents #2 referred as dose. Sunlight reassured ry by colony formation. heat .flaming, VI. C& ssific tion : hot air oven* incineration !* Moist heat sterilization. Moist heat .pasteurization, 3* boiling, ry heat sterilization steam under normal #* #hemical pressure,sterilization. steam under Sterilization is also classified as pressure* 5iltration .candles, asbestos filters membranes* $adiation 6ltrasonic vibrations. and sonic C'e$ic & #ents !lcohols Malogens ,henols &ases (thylene o'ide 3,4 beta propio lactone

$elationship is usually stated in turns of survivors because they are !ldehydes rying

S)n&i#'t : 3actericidal activity. &ermicidal activity because of 6 7 rays 8 heat. Studies have shown that in India, typed bacilli e'posed to sun on pieces of white drill cloth were killed in + hours where as controls kept in dark room were still alive after 9 days. D%(in# : Moisture is essential for the growth of bacteria :;<th by wt of bacterial cell consists of H+0 drying in air is deleterious effects on many bacteria. 6n reliable method. Spores are unaffected by drying. *e t : ry

Moist

Heat is the most reliable method of sterilization and should be method of choice unless contraindicated.

=illing by dry heat is due to ,rotein denaturation 0'idative damage 2o'ic effects of elevated of electrolytes.

D%( 'e t +F& $in#! : Inoculated loops wires point of forceps and scaring spatulas are held in 3unsen flame till they become red hot in order to be sterilized. If the loops contain infective proteinacious material they should be first dipped in chemical disinfectant before flaming to prevent spattering. Scalpel, needles, mouth of cultures tubes, glass slides cover slips etc are passel few times over the flame without allowing them to become red hot. 3acteria are destroyed by this method. Incine% tion : ('cellent method for destroying materials such as soiled dressings, animal carcasses, bedding and pathological material. *ot i% o,en : ry heat sterilization at )9>>#. Have heated members that allows air to circulate by gravity flow. Hot air is bad conductor of heat and penetrating power is low. Individual instrument must be heated at )9>># for ) hour for effective sterilization. 2ime reavised depends upon o o 0ven size Size of load

How instruments are packed.

Instruments packets must be placed atleast ) cm apart to allow heated air to circulate. If packed together without spacing ineffective sterilization. Dis -, nt #e : 2ime consuming procedure. High temp may damage rubber and plastic goods. Heavy load, crowding of packs can easily defect sterilization.

A-, nt #es : #arbon steel instruments and burs do not rust, collude, or lose their tamper or witting edge if they are died before procedure. 2o over come this lengthy time procedure, $H2S #o' manufacturing has introduced rapid heat transfer sterilizer .short cyclic high temp dry heat over*. 0perated at )?>># packed instruments )+min un wrapped instruments 9min. MOIST *EAT : !ction is by ,rotein denaturation. #oagulation of protein. !dvantage of steam lies in the blatant heat liberated when it condenses on a cooler surface raising the temp of that surfaces. In cases of spores steam condenses on the spores and kill them by hydrolysis and breakdown of bacterial protein. Te$. /e&o0 1222C :

,asteurization 9-># for ->min .holder method* or @+># for )</+> sec .flash forces* following by cooling Auickly to )-># by this process all non spacing pathogens such as mycobacterium brucella and salmonella are destroyed. 7accine bath bacterial vaccine are sterilized at 9>># for ) hour. Inspissator B> % B<># for ->min Iowenstein Censens and coeffies serum are rendered sterile for - successive days in an inspissator. Most heat resistant cells are the spore of clostridium botulinum % reAuire )+>># for :min. 2emperature at )>>># .3oiling* .)> % -> min* 7egetative bacteria are killed almost at ?>># % )>>># but sporing bacteria reAuire considerable periods of boiling. 3oiling is not recommended for surgical instruments. Hard water should not be used adding Hard water soft water +D 1aH #0 4id should not be opened during this period. Ste $ t t$os.'e%ic .%ess)%e 1222C : 6sed for sterilize culture media which may decompose if subjected to increase temperature. =och or !rnol steamer is usually used. Steam at normal atmosphericpressure )>>># ?> min. 5or media containing sugar or gelatin on e'posure of )>>># for +> min for - successive days is used % this is known as. T(n- &&i3 tion o% inte%$ittent ste%i&i3 tion :

2he principle is first e'posure kills all gram %ve bacteria and spares present will germinate in favourable medium and are killed in subseAuent occasion. STEAM UNDER PRESSURE +AUTOCLAVE! : 2emp. ,ressure / 2ime / Dis -, nt #e : #arbon steel instruments cannot be sterilized results in rusting corrodes or dulling. #ertain plastics and rubber are sensitive to heat and moisture cannot be placed in autoclave. Steam appears to corrode steel neck and shank portion of diamond instruments and carbide burs. A-, nt #es : Most rapid and effective method for sterilizing cloth surgical packs and towel packs. Ste%i&i3 tion of /)%s in )toc& ,es : 5or autoclave sterilization burs can be protected by keeping them submerged in a small amount of +D sodium nitrite <>D preparation % $otagerm of sodium nitrite crystals to ) litre of H+0*. !fter ultrasonic cleaning burs can be rinsed and placed in metal or glass beaker with a perforated lid. 5ill the beaker with sufficient fresh nitrite sol. to have it above the burs appro'. )cm place the container of burs and fluid into the sterilizer and operate a normal sterilization cycle. 2hen discord the fluid from the container through perforated lid. 6se store forcep to place )+,>c. )</)9 per sAuare, inch. )< % +> min

the burs into bur holder. Store the burs dry. !ny nitrite residue can be wiped or rinsed off with clean or sterile H+0 if desired. A-, nt #es of $oist 'e t o,e% -%( 'e t : Moist heat kills organisms and spores at lower temp and lower time. ,enetrating power is more for moist heat than dry heat. Fi&t% tion : 6seful for antibiotic solutions, sera, carbohydrate solution,etc. raw back" viruses and mycoplasma may pass through 2ypes used" (arthen/ware candles, e'" berkfeld, chamberland. !sbestos disc filter, e'" seitz. Sintered glass filters. #ollodion or membranous filter. RADIATION : Ionizing radiation .'/rays, '/rays cosmic rays*. 1on % ionizing radiation .infra red, 6.7 rays*. Ioni3in# % (s : 4ethal to 1! high penetration power. 6sed to sterilize plastic syringes latherers rubbers. Nonioni3in# : Infra red rapid moss sterilization of syringes. 67/rays 0peration rooms entry way virus laboratories hospital wards. ULTRASONIC AND SONIC VIBRATION :

 $esults are not good because microorganisms still survive after the ultrasonic and sonic vibration sterilization procedures.

C*EMICAL VAPOUR STERILIZATION +C*EMICLAVE !: 2his method is based on the factors of heat, water and chemical synergism. #hemicals include alcohols, formaldehyde. 2he water content is below the )<D level, above which rust, corrosion dullness of metal occur. #omposition of heat 8 chemicals is much kinder to metal surfaces than other tech. 2emperature )-)># and +> pounds pressure for +>min. A-, nt #es : #arbon steel and corrosion sensitive burs, instruments, and pliers are sterilized. Dis -, nt #es : 0dor is released when chemical are heated. ,eriodontal, $estorative and (ndodontic Instruments #arbon steel Instruments and 3urs !utoclave .0$* #hemical vapor pressure sterilizer

ry heat .0$* #hemical vapor pressure

VII. STERILIZATION MONITORING :

!* ,hysical monitoring " $efers to periodic observation of displays or gauges on the sterilizer during cycle o ensure sterilization process. !* #hemical monitoring 3* 3iologic monitoring

#hemical monitoring Heat sensitive chemical indicators .those that change color after e'posure to heat*. 2wo types of chemical used.

,rocess indicator paper

2.S, 2 strips .time, steam temp.*

3iologic monitoring is the only dependent method to determine sterility. 2hose monitors are composed of strips of paper with live, resistant spore which should be killed if properly sterilized. Should be done weekly. Spore types used for evaluating sterilization spore type used. !utoclave 3acillus #hemical vapor Staerothermophilus ry heat (to'

3acillus Subtilis

I4. PROCEDURE AFTER STERILIZATION :

D%(in# n- coo&in# of inst%)$ent : Instrument sterilized by moist heat are allowed to dry before handling. #ooling of warm packages must be done slowly and warm packs should not be transferred to cool surfaces or placed under air conditioning units. 6se of fans to cool down the warm instrument is not recommended because it can cause undue circulation of potentially contaminated air around the packs. Sto% #e : !fter sterilization % they should be kept in a cool dry protected area, above the floor a few inches away from walls and ceilings , away from sinks and heat sources. 4. DISINFECTION : It is a lethal process to kill disease producing microorganisms but not bacterial spores. ,rocess of disinfecting instruments, eAuipments by using a liAuid chemical germicides is called cold sterilization. 2ime period according to environmental protection agency .(,!* is )> hours. !fter immuring the instruments for a holding period than they should be rinsed with sterile water and thin drying should be done. Mec' nis$ of ction : ,rotoplasmic poision. amages the microbial cell membrane resulting in loss of vital cell constituents. &lutaraldehyde and formaldehyde appear to seal or fi' cell membrane and thereby block the progress of cellular component thus killing of organisms.

 Halogens by o'idizing agents. I-e & .%o.e%ties : / / / / / / Should have wide spectrum of action. Speedy action High penetrating power should be stable. 1ot corrode metals. 1ot to to'ic if absorbed in the circulating system. 1ot to interfere with healing.

A&co'o&s : 1ot accepted by ! ! for disinfection of instruments. A&-e'(-es : isinfection occurs in )>/->min various types of preparations are capable of sterilization. +D acidic 9>># for ) hour. +D alkaline room temp for )> hours. +D alkaline with phenolic buffer room temp for 9.@ < hours. +D neutral room temp for )> hours. &lutasaldehydes are generally not recommended for sterilization because of instability of activated solutions. isadvantage by the use of glutaraldehyde 7aporto'icity Hand and eye irritation ('pense C'&o%ine-io5i-e : 6sed to disinfect instruments and operatory surfaces in )/- min.

 Solution reavires no rinsing and leaves no reside after use. Solution can sterilize items in 9 hours at rooms temp. !dvantages non to'ic non sensitive non irritating N OC& : Suitable surface disinfection other than instrument sterilization. ivtions )") to )"< are recommended disinfection time -/-.> minutes 7irucidal, bactericidal, tubercolocidal. isadvantage, corrosive un pleasant older Io-o.'o%s : broad spectrum disinfectant including H37, M tuberculosis, ,oliovirus, Herpes Simple' virus. !dvantage " slow release of elemental iodine to enhance bactericidal activity. Hard H+0 inactivates iodophor. 3iocidal activity occurs within -> min. when iodophor solution is fresh it will be amber color as age of solution advances it changes to light yellow indicating loss of lodophor molecule. Iodophor solely disinfectant Sporicidal capabilities absent. Disinfection tec'ni6)es : !* Immersion disinfection 3* Surface disinfection #* econtamination of dental unit % #heck values have been recommended to fervent aspiration of infective materials into hand pieces of H+0 lines. 2he center for disease control recommends that hand pieces be flushed +> % -> sec. 3etween patient and several minutes at the disadvantages % corrosion

beginning of each day to redvice and over night bacterial accumulation in the units.

GASES : Fo%$ &-e'(-e # ses : 6sed for fumigation of operation theaters after sealing the windows and other outlets formaldehyde gas is generated by adding )<> gm of kmno: to +B> ml of formation. 2he reaction produces heat. 2here heat resistant vessels should be used. !fter fumigation door are left unopened for :B hours. Surfaces which have been disinfected by this agent may release on irritant vapor for sometime after disinfection and this can be nullified by e'posure to 1H- vapor after disinfection. Et'(&ene o5i-e : #olorless liAuid, boiling point )>@># !t normal temp and pressure it is highly penetrating pas with sweet small. Highly inflammable and e'plosive so other gases are added #0+ or 1+ 6sed for disinfection of heart lung machines respirators. Sutures, books and clothing.

INFECTION CONTROL FOR IMPRESSIONS AND RELATED REGISTRATIONS : #oncepts for transporting impressions and associated registrations to a remote laboratory. ,otentially infectious material shall be placed in a container which prevents leakage during collection, handlings, processing, transport.

#ontroversy regarding transport of potentially infectious item. i* ii* Sent it cleaned .rinsed* and undisinfected in a biohazard/ labeled, heat/sealed, plastic bag or ebride, clean .rinse* and adeAuately disinfect it place sealed transport bag. In either case most laboratories will disinfect the item to ensure protection of lab. ,ersonal disinfecting twice is time wasted and multiple e'posure to disinfectant should be avoided. 2he simplest and best approach is )st one. P%oce-)%es fo% ' n-in# n- t% ns.o%tin# .o&( ,in(& si&o5 ne o% %)//e% / se- i$.%ession $ te%i & n- n( ssoci te- %e#ist% tions to & /o% to%( : I.#. procedures regarding nanaAueous rubber impression and any associated registration are as follows " )* 3efore the patient appointment, prepare one or more clean, strong, clear, heat sealable, bionazard labeled plastic bags of appropriate size. 0ne for containing the scheduled impression and a separate one for any inter occlusal registration. ,lace bag into an open canister of suitable size so that the bags open end e'tends above the rim of the canister, allowing a slight folding downward outward of the bags open edge. 2his helps keep it open and also prevents contamination of the bags outer surface during insertion of item. +* $emove impression from mouth were still wearing gloves. $emove any attached debris and rinse the item well with running tap H +0 for )< sec. to remove saliva and blood. -* !fter rinsing and while still wearing barriers place impression into bag without touching the bags outer surface. %e$ote

:*

1ow remove gloves because they are contamina with clean hands, close the bag while touching only. 2he bags clean outer surface and heat seal it.

<* 9*

2ape the prescription to bag !ttach a note appropriately lettered to alert the laboratory that the item in the bag was debrided and rinsed but not disinfected send the bag to remote lab.

P%oce-)%es fo% ' n-&in# n- .o&( et'e% i$.%essions :

n- t% ns.o%tin# ite$s fo%

6)eo)s

i$.%ession $ te%i & tec' )s) &&( i%%e,e%si/&e7 %e,e%si/&e '(-%oco&&oi-s 1! 2horoughly rinse the impression under top H+0 .)< sec* to remove any saliva or blood. +* isinfect the impression by spraying unit thoroughly soaked with a hospital level disinfectant. 2he product with the shortest time allows less distortion. -* Eith clean hands thoroughly rinse the disinfected impression under top H+0 to avoid prolonged e'posure to the disinfectant D any residual disinfectant can adversely affect surface hardness or stone cast. :* Shake e'cess H+0 from impression and pour cast immediately. 0ne reversible hydrocolloid manufactures F7!1$G offers two alternatives to immediate pouring of impression after disinfection. i* ii* Submerge impression into +D potassium sulfate solution for +> min and then remove shake off e'cess and pour the impression. ,lace the impression into a humidor for upto : hours with no temp change remove and submerge into +D potassium sulfate <>D for +> min remove, shake of e'cess and pour the impression. <* 2he cast from a disinfected impression does not need to disinfected,

9* ,ack the cast for shipment to remote lab. Irreversible hydrocolloid ,oly sulfide silicone ,olyether $eversible hydrocolloid #hlorine compounds or lodophors &lutaraldehyde chlorine compounds lodophors phenolies #hlorine compounds iodophors +D potassium sulfate

4II. * n-.iece s)%f ce cont $in tion cont%o& n- ste%i&i3 tion : 3lood and saliva contaminate the surfaces of handpieces during various dental treatments irregular surfaces and especially crevices around the bur chuck are difficult to clean and disinfect. Submersion of high speed handpiece in a high level disinfectant has not been an option by manufuact. Scrubbing and applying disinfectant will reduce the no of bacteria but did not completely eliminate them. 0nly sterilization can completely bring infection control of handpiece surface. Handpieces are semicritical instruments. !utoclave sterilization of handpiece is one of the most rapid method. 5iber optic dim with repeated heat sterilization apparently due to oil residue and debris baked on the ends of optical fibers. #leaning with detergent sol and wiping ends of optics with alcohol will prolong use. P%oce-)%es fo% ' n-.iece 0it' $et & /e %in# t)%/ine : Scrub metal bearing high speed handpieces and sheath or cone of low speed handpiece at the sink with running water and detergent. 3ecause the handpiece and autoclave them. &)/e f%ee ce% $ic /e %in# t)%/ine :

P%oce-)%e fo% ' n-.iece 0it'

5or this type of handpiece avoid using chemicals because they damage internal parts. 5iber optics are cleaned by isopropyl alcohols.

3ag and autoclave the handpiece.

#hemical vapor pressure sterilization recommended for ceramic bearing handpieces. ('" (20H .ethylene o'ide* gas is used. 0il left in handpiece can impair sterilization in some (20H sterilizers gas appears to penetrate high speed handpieces. ry heat sterilization of handpiece is generally not recommended. 4III. STERILIZATION IN ENDODONTICS : $ubber dam sterilized by % +D benzalkonivm chloride in <>D isoprophylalcohol .0$* swabbing with H+0+ followed by tincture of iodine. i* ii* #old sterilization of instruments is not recommended for + reasons. ,rocess microorganitions. 4engthy procedure. #old sterilizing <>D is sporicidin % composition ,henol % @.><D Sodium tetraborate &lutaraldehyde Sodium phenate !bsorbent points, broaches, files and other root canal instruments % sterilized in Hot salt sterilizer. It consists of metal cup in which table salt is kept at temp :+<>5 and :@<>5 silver cones broaches, reamer, files < sec. !bsorbent point and cotton pellets )> sec. 3ring disinfection in )>min at room temp and sterilization in 9.@< hours is ineffective against all variety of

Hot salt sterilizer has superseded glass bead sterilizer and molten % metal sterilizer because metal and glass beads occasionally clung to a wet instrument, escaped detection and then clogged the root canal as instrument was instated. !dvantages of Hot salt sterilizers is )* 6se of ordinary table salt. +* (liminates the risk of clogging the canal. 6sual commercial table salt, contains a small amount .)D* of sod. Silicoaluminate, magnesium, carbonate, sod carbonate. ,ure 1a#l should not be used without these additives because high heat may cause fusion of the granules of salt. &lass beads may be effectively substituted for a salt in a hot salt sterilizer provided the beads are less than )mm in diameter. 4arger beads are not so effective in transfer of heat to endo instruments because larger air spaces between the beads reduce the efficacy of sterilizer. 0perating temperature :+>>5 to :@<>5 Hottest part of salt bath in sterilizer is along its outer rim, starting at the bottom layer of salt. 2emperature is lowest in the center of the surface layer of salt. 2o sterilize on instrument one should immerse it at least a greater inch below the salt surface and in peripheral area of the sterilizer. $oot canal instruments are immersed in not salt or gloss bead sterilized for < sec. .$ecovers, files breaches* and for )> sec. .absorbent points and cotton pellets*. appen dishes sterilized by swabbing with tincture of thimersol followed by alcohol.

 4ong handle instruments, tips of cotton plier blades of scissors sterilized by dipping the working point in alcohol and flaming twice. $oot canal instruments may be sterilized by autoclave % )<,9 pressure at )+># for )< min. ry heat autoclave may ie. 6sed to sterilize root canal instruments but this is time consuming because it reAuires an elapsed time of + hours for sterilization at ) hours for sterilization at -> min for sterilization at -+>>5 -:>>5 -B>>5

&utta/percha sterilized by immersion it in <.+<D 1a0#l for )min than rinse the cone with H+0+ and dry it between + layers of sterile gauge. Silver cones passing them over bunsen flame for - % : times. !lso sterilized by hot salt sterilizer < sec. ,yre' glass ware can with stand high temperature can be sterilized by autoclave or dry heat sterilization. 4IV. ADVANCES IN STERILIZATION : L se%s : Sterilization of root canal by #0+, 1d"I!&, He#l, (r"I!& is being tried. 1d"I!& is more popular because thin fiber optic delivery system is available for entering narrow root canal. Sterilization time % + sec. 4asers have bactericidal effect. MGP G)tt 8.e%c' martin and martin. Iodoform is centrally located within gutta/percha and takes about +: hours to leach to the surface. Iodoform inhibit microbial growth. : Medicated gutta/percha has been developed by

 Iodoform remains inert until it comes in contact with tissue fluids that activates the free iodine. REFERENCES 1. EFFICAC9 OF C*EMICAL STERILIATION AND STORAGE CONDITIONS OF GUTTA PERC*A CONES. a. . I(C,-:J9JS(,"+>>).*
:. T*E STERILIZATION OF ENDODONTIC *AND FILES.

a. .C0( J++J9JC61( )??9.* ;. *EPATITIS B IN DENTISTR9 : T*E CURRENT POSITION .3$I2. (12,)?B),)<>,B?/?).*

CONCLUSION : !s the saying stich oin timeK.saves nine goes, it is better to follow sterilization procedures and aseptic tecniAues rather than to suffer from diseases or cross infection.

<CLEANL9NESS IS NE4T TO GODL9NESS=