Instrument Processing

Module 5

Nancy Goodwin, CDA, RDH, MEd.

All rights reserved

Some things to think about

How do you decide if something should be

sterilized or if it can be disinfected?

How should sterilized items be stored?
How do you prepare items for
sterilization?
What would prevent something from
becoming sterilized in an autoclave?

Objectives
Upon completion of this instruction, participant will be able to:

Define the following classification of instruments: critical, semicritical, non-critical.

Discuss the five steps of instrument processing and the rationales and
procedures for each step.
List the approved methods for precleaning dental instruments.
List the three most common methods for sterilization of instruments.
Demonstrate the procedure for testing for proper ultrasonic function.
Describe the steps for cleaning and sterilization of highspeed dental
handpieces.
Describe the three forms of sterilization monitoring.
Explain the differences between process indicators and integrators.
Discuss the recommended schedule and the procedure for conducting
in-office biological monitoring.
Describe the CDC guidelines for sterilization and disinfection of
patient items.
Describe the CDC guidelines for preparation and packaging of dental
instruments prior to sterilization.

Classification of Patient-Care Items

In order to determine the appropriate
treatment for any item that has been
used in patient care, you will need to
classify them into one of the following
three categories:
Critical
Semicritical
Noncritical

Critical Items

Are defined as those

used to penetrate soft
tissue or bone

Since the risk of

transmission would
be high, they must be
heat sterilized

Examples:
Surgical instruments
Scalers
Forceps
Scalpels
Bone chisels
burs

Clinical Application
What do you use clinically everyday that is

considered a critical item?

How do you treat these items before they
are used again?

Semicritical Items

Touch mucous
membranes or
nonintact skin
Have a lower risk of
transmission.
However, if an item
can be heat sterilized,
it should be heat
sterilized.

Examples:
Mouth mirrors
Amalgam condensers
Impression trays
X-ray film holders

 Semicritical instruments which cannot

tolerate the high temperatures of

sterilization must be processed by using a
sterilant or high level disinfectant.
These products achieve sterilization (kills

all forms of life including spores) after

immersion in the solution for 3 to 10
hours. Follow manufacturers instructions
for the product in your office.

Clinical Application
Which items do you use daily which are

considered semi-critical?
Do you routinely sterilize these items?
If not, what is your method for assuring
that they have remained in the disinfectant
or sterilant for the necessary length of
time?

Immersion Disinfectants FDAApproved for use in dentistry

Sterilants:
Gluteraldehyde -6 to 10 hour contact time
Hydrogen peroxide (7.3%) 6 hour contact

time.
Gluteraldehyde and phenol/phenate-12
hour contact time
Hydrogen peroxide and peracetic acid-3
hour contact time

High level Disinfectants

Ortho-phthalaldehyde (12 minute contact time)
Gluteraldehyde- 20 to 90 minute contact time
Hydrogen peroxide- 30 minutes contact time
Gluteraldehyde and phenol/phenate- 20 minute
contact time
Hydrogen peroxide and peracetic acid-15 minute
contact time.

(remember to wear all recommended PPE when

dealing with these chemical disinfectants)

Definitions to remember.

Sterilization is the process that kills all

microorganisms and is considered the highest
level that can be achieved. It is accomplished by
the proper use of immersion chemical sterilants
or by heat.

High level disinfection is used when a

semicritical item cannot withstand heat
sterilization. Used correctly, it is intended to kill
disease producing microorganisms but not
spores. These products are not used for surface
disinfection, but for immersion.

Noncritical Items

Contact intact skin

only.
Have a low risk of
disease transmission.
Some of these (*)
should be precleaned
and disinfected or
barrier protected.

Examples:
Blood pressure cuff
*X-ray cone (PID)
Stethoscope
*Lead apron

Universal Sterilization
means that all reusable instruments
and handpieces are sterilized (rather
than disinfected) between use on
patients. This provides the highest
level of patient protection.

Miller & Palenik, p. 196

Instrument Processing Area

Instruments should not be processed in

the treatment area but be transported to a

central area.
The ideal instrument processing area
should have separate areas for dirty and
clean and should be set up in a linear or
u-shaped area for maximum efficiency and
safety.

 Remember to carefully transport

instruments to the sterilization area.

Ideally, they should be in closed cassettes
and handled with utility gloves.

http://www.hu-friedy.com

www.smartpractice.com

Instrument processing- linear pattern

Contaminated
Area

Packing
Area

Sterilization
And
Storage
Area

Contaminated area: throw away disposables, place instruments in holding

solution or preclean with ultrasonic cleaner or other approved method, dry instruments,
dip in rust inhibitors if applicable.
Packaging area: Place process integrators or biologic monitor (weekly), in packaging
fully wrap instruments, place process indicator tape on the outside of the package, label,
place in heat sterilizer. These will be discussed more later.
Sterilization and storage area: After sterilization is complete, store sterilized
instruments in their packaging, record results of spore tests.

 Instrument processing: U-shaped pattern

Sterilization
And
Storage
Area

Contaminated
Area

Packing
Area

Step by Step Instrument Processing

1.
2.

3.

Remove items from the operatory and

transport to processing area
Place the instruments, in their cassettes
in a detergent holding solution if they
cannot be cleaned immediately
The instruments, much like clinical
contact surfaces, must be cleaned
before sterilization to prevent the baking
on of debris.

Clinical Application
Is the sterilization area in your office

designed to follow the flow from

contaminated to clean?
Are sterilized items kept separate from
contaminated ones?
If not, how could you change the flow to
follow the recommended pattern?

Cleaning can be accomplished by two automated

approved methods:

Instrument washers- (which resemble a dishwasher

but are made to clean instruments; regular dishwashers
are not appropriate nor are they recommended)

Ultrasonic cleaners
Always use a recommended ultrasonic solution. Also,
establish a schedule for testing the effectiveness of the
ultrasonic. To do this, simply dip several inches of a
sheet of aluminum foil in the ultrasonic and turn on for
20 seconds. If the unit is functioning properly, the foil
will be full of indentations and holes. If not, a repair is
needed.

Ultrasonic cleaner
This solution is considered
highly contaminated. Retrieve
instrument cassettes while wearing
utility gloves

Dont forget to close the lid

during operation to reduce
aerosols!

They may also be cleaned manually, but this

presents more risk of an occupational
exposure.
If you must clean instruments manually,
wear all PPE, use a scrub brush with a long
handle, and scrub just a few at a time
while holding deep in a sink. Rinse and
inspect each instrument before packaging.
They should not have any debris
remaining.

Preparing and packaging- loose

instruments should be placed by procedure in
approved packaging if not in cassettes.
Unpackaged instruments are immediately
exposed to contaminants and are not
considered sterile.
5. Sterilization- Methods approved for dental
instruments are:
Autoclave (steam heat under pressure)
Dry clave (dry heat)
Unsaturated chemical vapor
Be sure to follow all manufacturers directions
regarding use to achieve sterilization.
4.

Take care not to overload steam heat sterilization equipment.

if steam cannot circulate and penetrate, instruments may not
be sterile.

6.

Store sterile and clean patient care

items
Instruments will remain sterile
indefinitely unless their packaging
becomes wet or torn. Generally, rotate
instruments so that you use the packages
sterilized earlier first (first in, first out).

If possible, store in a closed area where there

is no chance that they will become wet.
OSAP, p. 47

Instrument processing flowchart

Remove
Items from
operatory

Use holding
Solutions if
necessary

Clean by
Automated
Or manual
method

Store

Package

Sterilize

Sterilization Monitoring
To assure that sterilization equipment is
functioning properly and that
instruments are in fact sterile, dental
personnel must use various procedures
to monitor this process. The three forms
used are:
1. Physical
2. Chemical
3. Biologic

Physical Monitoring

Physical monitoring of equipment involves

checking and recording the readings on the
gauges for temperature, pressure and exposure
time. These readings indicate chamber
conditions (not individual pack conditions.)

Although this does not assure sterility of

instruments, the gauges are often a first sign that
something is wrong with the equipment.

Chemical Monitoring

Process Indicators
Are placed on the
outside of individual
packages before
sterilization. A change
in their color
indicates that the
pack was exposed to a
certain temperature
(NOT a test for
sterilization!)

Process
Integrators
Are placed inside
instrument packages
before sterilization.
They respond to the
temperature,
pressure, and time.
(NOT a test for
sterilization!)

Process Indicators

Do not indicate
sterility.
Simply indicate that
the autoclave reached
a certain temperature.
Show at a glance if a
load has been run.

Process Integrators

Should be placed inside

each cassette, especially
surgical packs.

May be single or
multiparameter

Indicate conditions inside

the individual cassette.

Not a test for sterility.

Single parameter

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Multiparameter:
Indicates all conditions for
sterilization have been achieved time, temperature, presence of steam.

Examples of
Process Indicators
Autoclave tape
Color changing
markings on
packaging

Examples of
Process
Integrators
Strips
Tabs
Tubes of liquid that
change color.

These indicators provide an immediate indication of the

conditions in sterilizing equipment.

Since they do not indicate sterility and should

always be used along with Biologic Monitoring.

Biologic Monitoring
Also called Spore Testing
Is the only way to determine if

sterilization has occurred

The CDC, ADA, and OSAP recommend
that each piece of sterilization equipment
be tested with a biologic monitor at least
once weekly.
Testing can be done in office or with the
use of a mail system.

In-Office
Incubator for
Biologic Monitoring

Biologic Monitoring Procedure

Be sure to choose the appropriate spore for
your equipment:

For autoclaves or chemical vapor sterilizers:

Bacillus stearothermophilis or
Geobacillus stearothermophilis

For dry heat sterilizers:

Bacillus subtilis or Bacillus atrophaeus

1.

Mark one monitor for each piece of equipment

to be tested and place the appropriate spore in
packaging

2.

Place in the middle of the sterilization

equipment with a full load of instruments

3.

Process through a normal sterilization cycle

4.

Record time, date and initial in sterilization

log.

5.

After the load has been run, remove

monitor(s), allow to cool, and place in
incubator or send to an approved monitoring
service.

6.

If you are conducting the monitoring in office,

place monitor(s) in incubator and replace the
lid. You will also need to place one Control
monitor in the incubator. This control does not
go through a sterilization cycle. Record the
time in log.

7.

Incubate all monitors for the recommended

time; usually 48 hours.

8.

At the end of the time period, remove the

monitors from the incubator and read the
results. The control should be positive (+) for
spores, all others should be negative (-).

The purple vials have been processed with a load of instruments and are Negative for spores
The yellow vial was the Control and is Positive for spores. A positive result in a test that was
processed indicates sterilization failure.

Biologic Monitoring Video

Click here to watch a

demonstration of the
Biologic Monitoring Procedure

Link

http://www.cdc.gov/oralhealth/infectioncon
trol/faq/sterilization_monitoring.htm
Find out from this link what can influence
the effectiveness of sterilization. Is there a
causes of failure that could be a factor in
your office?

Handpiece Sterilization
Because the dental handpiece is likely to

become contaminated with blood, saliva,

tooth fragments and restorative material,
they must be cleaned and heat sterilized
before use on another patient.
The two steps for this process are:
flushing
sterilization

Flushing procedures

Will increase the life of the dental handpiece

Will remove debris from the head of the
handpiece
Before flushing, clean any visible debris
To flush correctly, attach the intake tube to a
pressurized handpiece cleaner and flush to
remove debris. Then blow out the handpiece
with compressed air. Follow the manufacturers
directions for your particular equipment.

**note: running coolant water through the

handpiece does not run through the turbine
chamber where debris can collect and is
therefore inadequate.

Sterilization Procedure

After flushing, clean any visible debris from the

outside of the handpiece.
Package in approved packaging
Recommended methods:
Autoclave and chemical vapor
(other methods may be too hot)
Do not run a handpiece hot out of sterilization,
and do not run under cold water to cool. This can
damage the intricate metal parts.

Remember
As a dental auxiliary, you are legally and
ethically responsible for carrying out these
procedures as recommended by the CDC
and other agencies responsible for
infection control in dentistry.
Careful compliance with these
recommendations is intended to protect
you and the patients you serve.

References
Miller & Palenik, (2005). Infection Control

& Management of Hazardous Materials for

the Dental Team. St Louis,MO. OSAP,
Elsevier/Mosby.
From Policy to Practice: OSAPs Guide to
the Guidelines (2004).Annapolis, MD.
OSAP.