STERILIZATION AND DISINFECTION OF DENTAL INSTRUMENT

DECONTAMINATION

 Decontamination removes pathogenic microorganisms from objects

so they are safe to handle, use, or discard.
Instrument Processing Cycle
1. Cleaning
2. Inspection
3. Packaging (applicable to sterilization)
4. Sterilization/Disinfection
5. Storage and Delivery NON CRITICAL
6. Monitoring  Contact intact skin.
Categories of Patient-Care Items  Barrier protect or clean
and disinfect (if visibly soiled) using a low to intermediate-level (i.e.,
Spaulding Classification System tuberculocidal) disinfectant.
 Examples: x-ray head or cone, facebows, blood pressure
 Devised by Dr. Earle Spaulding
cuff.
 A rational approach to disinfection and sterilization which states that
instruments should be reprocessed according to the nature of the item
and the level of risk associated with their intended use
CRITICAL, SEMI-CRITICAL, NONCRITICAL
CRITICAL

 Penetrate soft tissue or contact bone, enter into or contact the

vascular system or other normally sterile tissue.
 Greatest risk of transmitting infection.
 Must be heat sterilized between use, or sterile single-use, disposable
devices must be used.
 Examples: surgical instruments and periodontal scalers.
SEMI-CRITICAL SINGLE-USE (DISPOSABLE) DEVICES

 Contact mucous membranes or non- intact skin (e.g., exposed skin  Intended for use on one patient during a single procedure.
that is chapped, abraded, or has dermatitis).  Usually not heat-tolerant.
 Lower risk of transmission.  Cannot be reliably cleaned.
 Should be heat sterilized or high-level disinfected.  Do NOT reprocess.
 Examples: mouth mirrors, amalgam condensers, and  Examples: syringe needles, prophylaxis cups, and plastic
reusable impression trays, handpiece, digital sensors. orthodontic brackets.
Factors Affecting the Efficacy of Disinfection and Sterilization
 Number and location of microorganisms
 Innate resistance of microorganisms
 Concentration and potency of disinfectants
 Physical and chemical factors
 Organic and inorganic matter
 Duration of exposure
 Biofilms
Decreasing order of resistance of microorganisms to disinfection and
sterilization
CLEANING
 Is the removal of foreign material(e.g., organic and inorganic
material) from objects and surfaces and normally is accomplished
manually or mechanically using water with detergents or enzymatic
products
 Physical removal (including prions) but not necessarily killing of
microbes
 Cleaning should always occur before disinfection or sterilization.
Presence of debris can compromise the disinfection or
sterilization process.
 Automated or manual.
 Ideally, instruments should be cleaned as soon as possible after use,
i.e. within 10 minutes
 Use carrying containers to transport contaminated instruments.
 Wear personal protective equipment.
Instruments should be presoaked in a non-ionic or enzymatic
detergent solution or rinsed to prevent drying of blood and to soften
or remove blood from the instruments.
FIXATION
 Is a chemical process that takes about 30 minutes at room
temperature, but is faster at higher temperatures.
 Proteins in blood and saliva left on the instrument are absorbed and
then fixed onto the surface of the instrument which could corrode
stainless steel instruments leading to pitting and rusting of the
surface.
AUTOMATED CLEANING
 Ultrasonic cleaning
 Instrument washer
 Washer-Disinfector
ULTRASONIC CLEANING
 Ultrasonic cleaning removes soil by cavitation and implosion in
which waves of acoustic energy are propagated in aqueous solutions
to disrupt the bonds that hold particulate matter to surfaces
INSTRUMENT WASHER
 Instrument washers are designed, tested, and FDA-approved as
medical instrument cleaners to operate many cycles per day in order
to facilitate efficient reprocessing of a practice's limited number of
instruments. These washers can save time by eliminating the need to
manually rinse or dry the instruments.
WASHER-DISINFECTOR
  Washer-decontaminators/disinfectors act like a dishwasher that uses  Packaging materials (e.g., wrapped or container systems) allow
a combination of water circulation and detergents to remove soil. penetration of the sterilizing agent and maintain sterility of the
 Washer-disinfectors are generally computer-controlled units for processed item after sterilization.
cleaning, disinfecting, and drying solid and hollow surgical and
Types and Use of Sterilization Packaging Materials
medical equipment.
MANUAL CLEANING

 This is a fallback practice, not recommended by the CDC. It Sterilization Packaging Acceptable
demands the most time and effort and carries the highest risk of Method Material Materials
Requirements
sharps accidents.
Should allow steam Paper, Plastic, Cloth,
 Wear heavy-duty utility gloves, mask, eyewear, and protective Steam  autoclave to penetrate  Paper/plastic peel
clothing. packages, Wrapped
 Use non-foaming detergent perforated cassettes
 Use a long-handled nylon brush, not abrasive pads or wire
brushes. Dry heat  Should not insulate Paper bags,
 Thoroughly rinse instruments with tap water and ensure all items from heat Aluminum foil,
debris and detergent residue is removed. Polyfilm plastic
Should not be tubing, Wrapped
 Dry instruments with non-linting disposable paper towel
destroyed by perforated cassettes
INSPECTION temperature used
Unsaturated Vapors should be Wrapped perforated
 Each instrument should be critically inspected after each cleaning chemical allowed to cassettes, Paper
for residual debris or damage. Replace instruments as needed and vapor precipitate on Paper/plastic peel
never sterilize “dirty” instrument. contents packages
 Check each instrument for proper function and lubricate as
required by the instrument manufacturer. Hinged instruments with Vapors should not
stiff joints may be a sign of inadequate cleaning. react with
packaging material
PACKAGING
Plastics should not
 Wrap, package, or place instruments in containers before heat contact sides of
sterilization sterilizer
 Follow manufacturer’s instructions.
STERILIZATION POUCHES
 Place a chemical indicator inside each package.
 Label the package with the following:  Sterilization pouches are for packaging single instruments and
 Sterilizer number. small, lightweight items. Paper/plastic pouches allow you to see the
 Cycle or load number. contents and come with a build in adhesive strip for seal sealing. It is
 Date of sterilization. important to remove all excess air, prior to sealing the sterilization
 Expiration date, if applicable. pouch.
STERILIZATION WRAP  Odorless
 Economical
 Sterilization wrap is ideal for packaging dental cassettes.
 Solubility
 For sterility maintenance, be sure to use two layers of wrap per
 Stability
industry standards, and the wrap mfg’s FDA clearance.
 Cleaner
DISINFECTION  Environment friendly
 Describes a process that eliminates many or all pathogenic LEVELS OF DISINFECTANTS
microorganisms, except bacterial spores, on inanimate objects
LEVEL PROPERTIES EXAMPLE
 Disinfection reduction of the microbial load to a level that makes the
High level Kills all Aldehydes, Hydrogen
disinfected object safe to handle
Disinfectant microorganisms and peroxide, peracetic
ACTION OF ANTIMICROBIAL AGENTS reduces levels of acid, chlorine
spores at
TERM ACTION EXAMPLES practical exposure
Bactericide Agents that kills Chlorhexidine, Ethanol times
bacteria Intermediate Kills all Alcohols, Halogens
Biocide Agents that kills living Hypochlorite level microorganisms except
organism disinfectant spores
Fungicide Agent that kills fungi Ethanol Low level May kill most Phenols, Surfactants,
Germicide Chemical agent that Formaldehyde, Silver, disinfectant vegetative Alcohols, Heavy
(Microbicide) specifically kills Mercury bacteria, some fungi, metals
pathogenic some viruses
microorganism
Sporicide Agent that kills Glutaraldehyde
bacterial endospores CHEMICAL DISINFECTANTS
Virucide Inactivates viruses so Cationic detergents  Alcohols
that they lose the
ability to replicate  Halogens (Chlorine, Iodine)
 Aldehydes (Formaldehyde, Glutaraldehyde, OPA)
 Phenols (Cresol, Lysol, xylenol)
PROPERTIES OF AN IDEAL DISINFECTANT  Oxidizing agents (Hydrogen peroxide, peracetic acid)
 Broad spectrum  Surfactants (Quaternary ammonium compounds)
 Fast acting ALCOHOL
 Not affected by environmental factors
 Nontoxic  These alcohols are rapidly bactericidal rather than bacteriostatic
 Surface compatibility against vegetative forms of bacteria; they also are tuberculocidal,
fungicidal, and virucidal but do not destroy bacterial spores.
 Residual effect on treated surfaces
 Mechanism of action: denaturation of proteins
 Easy to use with clear label directions
 Disadvantages: Inflammable, mucous membrane irritant,
PROPERTIES OF AN IDEAL DISINFECTANT promotes rusting
CHLORINE  Mechanism of action: Alkylating ammino and sulfhydral
groups of protein
 Hypochlorites are the most widely used chlorine disinfectants  Disadvantages: potencial carcinogen, irritating fumes and
 They have a broad spectrum of antimicrobial activity, do not leave pungent odor
toxic residues, are unaffected by water hardness, are inexpensive and
fast acting, remove dried or fixed organisms and biofilms from GLUTARALDEHYDE
surfaces, and have a low incidence of serious toxicity
 Is a saturated dialdehyde that has gained wide acceptance as a high-
 Should be prepared daily because of instability of NaOCl solution
level disinfectant and chemical sterilant
 Disadvantages: Corrodes metal, inactivated by inorganic
 HLD with 2% buffered solution for a minimum of 20 minutes
matter, discolors fabrics, relative stability
exposure
BLEACH DILUTION CHLORINE LEVEL  Mechanism of action: alkylation of sulfhydryl, hydroxyl,
IN PPM carboxyl, and amino groups of microorganisms
5.25-6.25% None 52500-61500 (5 liter)  Disadvantages: skin and mucosal irritant
1:10 5250-6150 (4500-500)
1:100 525-615 (4900-100) ORTHO-PHTHALALDEHYDE (OPA)
1:1000 53-62 (4950-50)  OPA is effective (>5-log10 reduction) against a wide range of
microorganisms, including glutaraldehyde-resistant mycobacteria
 1000 ppm = M.tb and B. atrophaeus spores
 500 ppm = Candida in 30 seconds  HLD with 0.55% buffered solution in 5 mins at a minimum of 25°C
 100 ppm = B. Atropheaus in less than 5 minutes, 106-107 S. Aureus, or 12 mins at room temperature
Salmonella, Proteus, Pseudomonas  Mechanism of action: same as glutaraldehyde; blocks spore
germination process
IODOPHORS AND IODINE  Disadvantages: skin staining
 Iodine solutions or tinctures long have been used by health PHENOLS
professionals primarily as antiseptics on skin or tissue. Iodophors, on
the other hand, have been used both as antiseptics and disinfectants  Not effective against nonenveloped viruses and spores
 Tuberculocidal, fungicidal, virucidal, and bactericidal at their  Maintain activity in the presence of organic material
recommended use- dilution (1:100)  Use with manufacturer’s instructions
 Mechanism of action: disruption of protein and nucleic acid  Mechanism of action: penetrates and disrupts cell wall
structure and synthesis  Disadvantages: not used for semicritical items; evidence of
 Disadvantages: Requires prolonged exposure time hyperbilirubinemia in infants

FORMALDEHYDE HYDROGEN PEROXIDE

 Sold and used principally as a water-based solution called formalin  Stable and effective disinfection of inanimate surfaces
 The aqueous solution is a bactericide, tuberculocide (4% with 2 min  Active against a wide range of microorganisms, including bacteria,
exposure), fungicide, virucide (2%) and sporicide (4% with 2 hr yeasts, fungi, viruses, and spores
exposure)
  Mechanism of action: producing destructive hydroxyl free  Disadvantages: not sporicidal and generally not
radicals that can attack membrane lipids, DNA, and other tuberculocidal or virucidal against hydrophilic
essential cell components (nonenveloped) viruses
 Disadvantages: chemical irritation
Other Disinfection Methods
ACTION CONCENTRATION EXPOSURE
Bactericidal and 0.5% 1 minute  Heavy metals
virucidal  Ultraviolet radiation
Mycobactericidal and 0.5% 5 minutes  Pasteurization
fungicidal  Flushing- and washer-disinfectors
Sporicidal 3% 150 minutes
HEAVY METALS

 A new, rapid-acting 13.4% hydrogen peroxide formulation (that is
not yet FDA-cleared) has demonstrated sporicidal, mycobactericidal,
fungicidal, and virucidal efficacy. Manufacturer data demonstrate
that this solution sterilizes in 30 minutes and provides high-level
disinfection in 5 minutes
 Metals such as silver, iron, and copper could be used for
environmental control, disinfection of water, or reusable medical
devices or incorporated into medical devices
 Mechanism of action: alters shape ofproteins inhibiting
their function

PERACETIC ACID ULTRAVIOLET RADIATION

 Rapid action against all microorganisms
 Enhance the removal of organic material and leaves no residue
 Remain effective in presence of organic matter and is sporicidal even
at low temperature
 35% peracetic acid, is diluted to 0.2% with filtered water at 50oC in
automated machines
 Mechanism of action: denaturation of proteins, disrupts cell
wall permeability, oxidizes sulfhydryl and sulfur bonds in
proteins
 Disadvantages: unstable with 24-hr use life, tarnishes metal
QUATERNARY AMMONIUM COMPOUNDS
 The quaternaries are good cleaning agents, but high water hardness
743 and materials such as cotton and gauze pads can make them less
microbicidal because of insoluble precipitates or cotton and gauze
pads absorb the active ingredients, respectively.
 Mechanism of action: inactivation of energy-producing
enzymes, denaturation of essential cell proteins, and
disruption of the cell membrane
 Its maximum bactericidal effect occurs at 240–280 nm (wavelength)
 The application of UV radiation is limited to destruction of airborne
organisms or inactivation of microorganisms on surfaces
 Its germicidal effectiveness and use is influenced by organic matter;
wavelength; type of suspension; temperature; type of microorganism;
and UV intensity, which is affected by distance and dirty tubes
 Mechanism of action: destruction of nucleic acid
PASTEURIZATION
 Process developed by Louis Pasteur of heating milk, wine, or other
liquids to 65– 77°C (or the equivalent) for approximately 30 minutes
to kill or markedly reduce the number of pathogenic and spoilage
organisms other than bacterial spores
 Pasteurization of respiratory therapy and anesthesia equipment is a
recognized alternative to chemical disinfection
STERILIZATION
 Describes a process that destroys or eliminates all forms of microbial
life and is carried out in health- care facilities by physical or
chemical methods
 Killing and removal of all micro‐organisms including bacterial
spores