OPERATORY ASEPSIS

q Sterilization: refers to the use of a physical or chemical

procedure to destroy all forms of microorganisms (bacteria,
fungi, viruses) including the highly resistant spores.
q Cold Sterilization: sterilization at room temperature.
q Disinfection: destruction of pathogens by directly applied
chemical or physical means. It is less lethal and is intended to
kill microorganisms, but not bacterial spores.
q Antiseptic: is a chemical agent that stops the growth of
bacteria, but does not kill them.
Disinfection may be:

v High-level disinfection: destroy all microorganisms, with the

exception of large numbers of bacterial spores.
v Intermediate disinfection: inactivates Mycobacterium
tuberculosis, vegetative bacteria, most viruses, and most fungi;
does not kill bacterial spores.
v Low-level disinfection: can kill most bacteria, some viruses,
and some fungi; cannot be relied on to kill resistant
microorganisms such as tubercle bacilli or bacterial spores.
Spectrum Vegetat Myco- Spores Fungi Viruses Examples
of activity ive bacteria
cells

High level + + + + + Ethylene Oxide,

Gluteraldehyde,
Formaldehyde

Intermedi + + - + +
ate Phenolics,
level halogens

Low level + - - + +/- Alcohols,

quaternary
ammonium
compounds
Vegetative cell: a cell of a bacterium or unicellular alga that is
actively growing rather than forming spores.

Mycobacterium genus of gram positive, aerobic.

It contains many
species, including the highly pathogenic organisms that cause
TUBERCULOSIS and LEPROSY.
The efficacy of different disinfectants:

• There is no ideal disinfectant and the best compromise should be

chosen according to the situation.
• A disinfectant solution is considered appropriate when the
antimicrobial activity and the toxicity of the product is satisfactory for
the given application.
• The more active disinfectants are the more toxic ones; potentially
toxic products can be applied to inanimate objects or surfaces,
whereas for disinfection of human tissues only the less toxic
disinfectants can be considered.
 OPERATORY ASEPSIS
v Currently there are seven major active ingredients used for
disinfectants in dentistry worldwide. They are
1.Alcohol
2.Chlorohexidine
3.Chlorine
4.Formaldehyde
5.Glutaraldehyde
6.Iodophores And Iodines
7.Phenolics
8.Hydrogen Peroxide
9.Peracetic Acid
10.Quaternary Ammonium Compounds
1-Alcohol (Ethyl alcohol and isopropyl alcohol)

§ Methyl alcohol is much weaker and not recommended.

§ They have their best disinfectant power at concentrations between

60% and 90% dilution in water; very poor below 50%.

§ They require a wet contact for at least five minutes to disinfect,

therefore simple wiping with alcohol cannot be considered as
intermediate disinfection. Wiping with alcohol is a low level
disinfection.
1-Alcohol (Ethyl alcohol and isopropyl alcohol)

§ Ethyl alcohol is a potent bactericidal agent (five minute for all

hydrophilic viruses).

§ Isopropyl alcohol is equally effective on bacteria but lacks

effectiveness against enteroviruses which lack lipid envelopes.

§ NOT for sterilization because of lack of action on spores

§ It is unable to penetrate proteinaceous material (blood and tissue

fluid)

§ flammability is a major safety problem

§ evaporation may lead to insufficient contact time

2- Chlorine:
q Sodium hypochlorite (NaClO), Clorox, household bleach:
5% solution
q Extrait de Javel: 15% solution of NaClO
q Calcium hypochlorite (powder, granules or tablets) with
70% Cl
q Demand release chlorine dioxide
q The disinfectant power of all chlorine releasing compound
is expressed as available chlorine in ppm (parts per
million):
q 1mg/litre = 1 ppm = 0.0001%
q Some countries express the chlorometric degree
(1°=0.3%)
q Bleach = 5.25% or 52,500 ppm NaClO
 2- Chlorine:

For 24 hr. 1: 10 5000 ppm 1: 50 1000 ppm

1:100 500 ppm 1:500 100 ppm
q Kills vegetative bacteria and inactivates HBV at 500 ppm
in 10 minutes.
q Inactivates HIV at 50 ppm in 10 minutes.
q It does not destroy spores.
q It is recommended at 1:10 dilution for disinfection of
blood spills.
q For disinfection of counter tops and work surfaces,
laundry, and dental impressions at dilutions of 1:100.
q Advantages: Low cost, Low level of toxicity or irritancy
2- Chlorine:
q Shortcomings:
I. Difficult to combine with detergents
II. Corrosive to metals
III. Damages some plastic equipment
IV. Unstable over time: Ca hypochlorite is more stable than
Na hypochlorite.
V. Inactivated by organic matter
VI. Hazardous when coming in contact with formaldehyde or
with acid (carcinogenic chlorine gas is released).
VII.chlorine solutions should be prepared daily.
q The concentration at 30 days in a translucent container was
40% of the original concentration (Rutala 1998. IC&HE
19:323).
q That is why for 30 days, twice the amount she be used.
3- Formaldehyde

v It was used as a disinfectant and sterilant in gaseous or

liquid form.
v The commercial preparation of Formalin is a liquid
formulation with 37% formaldehyde, 10% methanol and
water.
v Formalin kills vegetative bacteria, fungi and viruses in less
than 30 minutes, spores in several hours.
v Formaldehyde fumes are a strong irritant and are a
potential carcinogen. For this reason it is no longer used in
most hospitals.
v If used, equipment should be thoroughly rinsed after
disinfection.
4- Glutaral (Cidex® = 2% glutaraldehyde)

• It is commonly used as a high level disinfectant (30 minutes contact)

or even as a chemical sterilizer (10 hours contact).
• It is sold as a 2.5% solution to be activated.
• Aqueous solutions are acidic and are not sporicidal.
• Once they are made alkaline (activated) at pH 7.5 to 8.5 they become
sporicidal but they have a shelf life limited to 14 days due to
polymerization that occurs at alkaline pH.
• Formulations of glutaraldehyde with phenol have a longer shelf life
(up to 28 days).
4- Glutaral (Cidex® = 2% glutaraldehyde)

Advantages:
i. Not corrosive to metals
ii. Good to rubber and plastics
iii. Active in presence of organic matter to some extent
iv. No coagulation of proteinaceous material
4- Glutaral (Cidex® = 2% glutaraldehyde)
Shortcomings:
i. irritation it may occur to health care workers exposed it in
poorly ventilated areas.
ii. Unstable, activity should be monitored. Monitoring strips (‘dip
in the solution’ type) are available from the various suppliers of
glutaraldehyde preparations. However, the strips need to be
chosen to be compatible with the particular chemical
formulation of the preparation in use. Chemical analysis of
sample(s) of the solution in a laboratory is the only alternative
to monitoring strips
iii. Leaves some residue on metals

Uses:
• Cold sterilizer for heat-sensitive items which cannot be
autoclaved or gas sterilized:.
5- Hydrogen peroxide
• Hydrogen peroxide (H2O2) is available commercially as a 3%,
6% solution or as a 30% stabilized solution.
• It takes hours to kill spores but kills all other microbial forms in
less than one hour.

Shortcomings:
• 30% concentrate is very corrosive.
• It should be stored in a cool place and protected from the light.
• It is only used for surface disinfection
6-Peracetic acid

• They are stabilized solutions of hydrogen peroxide, acetic acid and

peracetic acid.

• It is sporocidal in low concentrations (0.01% - 0.2%, 100 ppm - 2000

ppm).

• Kills vegetative forms in five minutes at 100 ppm, in five minutes at

500 ppm in presence of organic matter, kills all viruses in 15 minutes
at 2200 ppm, inactivates spores in 15 seconds at 10,000 ppm (1%),
or in 15 minutes at 500 ppm.

It can be used as a disinfecting agent for liquid immersion.

Advantages:

i. Rapid action
ii. No harmful decomposition products
iii. No residue
iv. Effective in presence of organic matter

• Shortcomings:

i. Corrodes metals
ii. Unstable: a 1% solution loses its strength in 6 days
Uses:

• Automated machines use peracetic acid to sterilize

medical, surgical and dental equipment.
• There are two peracetic acid solutions approved by the
FDA for use as sterilants or high-level disinfectants.
• One is for single use in an automated system (Steris®).
• In this system, concentrated (35%) liquid peracetic acid.
• A second solution is provided pre-diluted and ready to use.
The formulation is reusable up to 14 days.
• Unlike the more concentrated solutions, this ready-to-use
solution is not a skin irritant and does not cause dermal
sensitization. However, it is corrosive to ocular tissue.
Iodophors:

• The iodophors are a combination of iodine and a solubilizing

agent (Povidone-Iodine, Clinidine, Betadine) with a
concentration of 10% iodine (yielding 1% free iodine).
• Some are formulated as disinfectants, others as antiseptics.
• Good to kill bacteria. Ability to kill small hydrophilic viruses is
questionable. Does not kill spores.

Advantages:
• Povidone iodine does not stain, does not irritate
• Rapid action
Shortcomings:
i. Tincture of iodine is staining and irritant
ii. Gram negative bacteria can survive and grow in iodophors.
iii. Lose effectiveness after drying
iv. Corrosive to metals: particularly aluminum and copper
v. Damages rubber and plastics
Uses/Misuses:
i. NOT for damaged/diseased skin or tissue
ii. Superficial disinfection of the skin preoperatively.
iii. Antiseptic iodophors should not be used as surface
disinfectants.
iv. Immersion at 15minutes in a 2.5% solution (one part 10%
solution with three parts sterile water) provides high Level
disinfection for clean equipment. Solution should be prepared
fresh every day.
v. This is rarely used in western hospitals.
Phenolics
• They have been used for a long time as
hospital disinfectants. Ortho-phenyl
phenol (PP) and o-benzyl-p-
chlorophenol (BCP)
• Kills easily vegetative forms of
bacteria and fungi, but inactive against
hydrophilic viruses and bacterial spores
• A 0.5% dilution of PP or BCP
inactivates HIV.
• Some doubts exist about activity
(>10min to inactivate polio virus).
Advantages:
Cheap -Residual film may be left on
disinfectant surface
Shortcomings:
i. Slow acting: wet contact for 10 minutes to get disinfection
ii. Absorbed by porous materials, may be released even after
thorough rinsing
iii. Skin irritation, depigmentation
iv. Irritation of tissues if instruments are not thoroughly rinsed
v. Gloves and goggles are to be used when applying in large
quantities
vi. Gram negative bacteria can survive and grow in phenolic
solutions

Uses/Misuses:
i. NOT used for skin disinfection
ii. NOT for disinfection of semicritical item
iii. NOT for anything that comes in contact with patients
iv. It is only used for disinfection of environmental surfaces
Quaternary ammonium compounds
All contain a nitrogen with four radicals:
These are cationic compounds (+), they are incompatible with
soaps (anionic -).
Advantages:
i. Not irritating
ii. Detergent action
iii. Shortcomings:
iv. Gram negative bacteria may grow in solutions.
v. Lack of activity on spores, hydrophilic viruses and
mycobacteria.
vi. Activity depressed in contact with organic matter
Uses/Misuses:
i. NOT to be used as skin antiseptic
ii. NOT to be used for disinfection of semicritical items
iii. It is only used for disinfection of environmental sanitation
(floors, furniture, walls).
 OPERATORY ASEPSIS
1- DISINFECTION

Proper disinfection can be achieved by

using one of several chemical agents
* Sodium hypochlorite (household
bleach) diluted with water in ratio of 1:5.
* Glutaraldehyde 2% neutral (Glutarex )
for 10 minutes at room temp.
* Chlorine dioxide ( Exspor) for 2
minutes at room temperature.
* Disinfection should be followed by
vigorous scrubbing.
 OPERATORY ASEPSIS
vThere are some critical factors that affect the
efficiency of the disinfectant.

a) Concentration b) active ingredient

c) contact time d) clinical indications for usage

v Over dilution has always been a serious problem.

vClinical Research Associates (CRA) tests data show

that high ethyl alcohol/phenolic formulations and
glutaraldehyde 2% are two active ingredients that
have opposite clinical indications.
 OPERATORY ASEPSIS
LABORATORY RAMIFICATION
vDental prostheses, appliances and items used in their
fabrication are potential sources for cross-contamination.

vThey should be thoroughly cleaned of all debris,

disinfected and thoroughly rinsed as soon as possible after
removal from the patient's mouth and before drying of
blood or other organic debris.

vThen placed in an impervious bag before being handled to

the laboratory.
 OPERATORY ASEPSIS
LABORATORY RAMIFICATION
• Manufacturers’ instructions should be consulted regarding the
stability of specific materials during disinfection.
• A separate receiving and disinfecting area should be established in
the laboratory to reduce contamination.
• It is recommended to spray the impressions with P-chlorophenol 1%
( omni ii ) before pouring the model.
• This procedure does not compromise the dimensional stability of the
impression materials.
 OPERATORY ASEPSIS
LABORATORY RAMIFICATION

• Laboratory staff should wear appropriate PPE (mask, gloves

and protective eyewear).
• laboratory items should be heat sterilized between patients
or discarded.
• Items that do not normally contact the patient, prosthetic
device or appliance should be cleaned and disinfected
between patients.
• Environmental surfaces should be barrier-protected or
cleaned and disinfected in the same manner as in the
dental treatment area.
• Dental laboratory staff should dispose sharp items in
puncture-resistant containers.
 OPERATORY ASEPSIS
LABORATORY RAMIFICATION
• Appliances and prostheses delivered to the patient should be placed
in a tamper-evident (security seal) container before returning the
item to the dental office.

• If such documentation is not provided, the dental office should

provide final disinfection procedures.

Tamper-evident tape tamper-evident plastic tie

tamper-evident bag
 Steps of sterilization:

1. Instruments processing and cleaning

2. Instruments preparation and packaging
3. Instruments Sterilization
4. Instruments Sterilization Monitoring
5. Instruments storage
1. Instrument Processing and Cleaning
Manual instrument cleaning
v Wear puncture and chemical resistant
heavy duty utility gloves, mask,
protective eyewear, and long-sleeved
protective clothing during cleaning. The picture can't be displayed.

v Head/shoe covers may be required.

v Instruments can be placed directly into
2.5% glutaraldehyde for 40 minutes and
rinsed.
v All visible blood, cement debris and
other contamination should be removed
from instruments before the sterilization
procedure.
1- Instruments processing and cleaning
vUse carrying containers to transport contaminated
instruments from the operatory room to the instrument
processing area.
vAutomated equipment is preferable to manual hand
scrubbing.

vIf hand scrubbing is unavoidable, the use long

handled brush and personal protective equipment are
mandatory.
FIRST STEP soaking the instruments in a disinfectant
to soften and loosen debris, blood and saliva.

SECOND STEP vigorous scrubbing using a brush or

ultrasonic cleaning containing a detergent or a
disinfectant.

THIRD STEP instruments are washed under running

water, dried and packed before sterilization.

The picture can't be displayed.

Ultrasonic cleaners
v It is safer and efficient than hand scrubbing, especially for burs
and endodontic files.
v They operate at 35–55 kHz wavelength and can actually tear
the biofilm away from the instruments.
v The ultrasonic cleaner should be operated
at least 1.5 minutes per instrument.

v It is not considered a sterilizer.

v The "cleaned" instruments will still be

contaminated and the cleaning solution

will be contaminated with live

microorganisms.
2. Instrument Preparation & Packaging
• Before sterilization, inspect instruments for cleanliness.
• Dry the instruments properly using disposable paper towels.
• Wrap or place them in packages to maintain sterility during
storage.
• Each instrument should be placed separately in a sterilization
pouch and should not be heavily packed with many
instruments in one pouch.
3. Instrument Sterilization:

Heat-tolerant dental instruments are sterilized in a

dental office using:

1. Steam pressure sterilization [autoclave].

2. Chemical vapor pressure sterilization [chemiclave].
3. Dry heat sterilization [dry clave]
Each method has very specific requirements
regarding:

a- time
b- temperature
c- suitable packing of materials
d- kinds of items and materials that can be safely and
effectively sterilized.

Ignoring any of these specifications can lead to improper

sterilization, damage materials or instruments.
Use FDA-cleared medical devices.

1. Do not overload the sterilizer.

2. Sterilization times, temperatures and other operating
parameters should be used as recommended by the
specific manufacturer of the equipment used.
3. Items should be arranged in the sterilizer in such a
way to permit free circulation of the sterilizing agent
(i.e., steam, dry heat or chemical vapor).
4. Instrument packs should be allowed to dry inside the
sterilizer chamber before removing and handling, in
order to avoid transmission of microorganisms from
air, hands or gloves.
 • Infra red
• chemiclave • Hot glass beads sterilizer

• Cidex OPA
• VHP MD series
• Peracetic acid

• Ultraviolet rays
A- High temperature/pressure sterilization
A- High temperature/pressure sterilization

1- Steam pressure sterilization (Autoclave)

It uses steam under pressure.

There are two cycles either:
*Short cycle at 134°C (30 psi) for 7 minutes.
* Long cycle at 121°C (15 psi) for 15-20 minutes.
Steam pressure sterilization (Autoclave)

Advantages:
1.This is the most efficient method of sterilization as it is
rapid and effective.

2.There is good penetration, it can sterilize paper- wrapped

instruments, surgical packs or towel packs.

3.It maintains integrity of liquids, like handpiece lubricants,

due to the 100% humidity within the chamber.
Steam pressure sterilization (Autoclave)

It has some disadvantages:

1. Non stainless steel metal items

corrode as steel and carbon steel burs.

2. It may damage heat sensitive items.

3. Sharp instruments get dulled.

4. Requires use of distilled water

5. Small chamber size necessitates

frequent cycles.
Steam pressure sterilization (Autoclave)

vBurs can be protected by being

submerged in a small amount of
2% sodium nitrite placed in a
metallic container with a
perforated lid.

vAfter sterilization the fluid is

drained the burs should be wiped
with sterile gauze
Portable bench top steam sterilizers (formerly called autoclaves)
There are several types of sterilization cycles including:
• N class cycles – used for unwrapped, solid items.
• S class cycles –used with multi-pulse vacuum steam sterilizers to
suit loads of certain types and configurations
• B class cycles ( the most commonly used one)– for hollow
objects.
• Air is exhausted by a
mechanical pump to
create a vacuum before
steam is introduced into
the chamber.
• Some steam sterilizers are
capable of being operated
through more than one
kind of cycle, depending
on the circumstances and
the type of instruments.
 A- High temperature/pressure sterilization
Drying
• Steam sterilizers must have a dedicated drying cycle so that a
dry load is produced.
• Forced cooling of items by external fans or boosted air
conditioning must not be used.
• In those units without a drying cycle, allow instruments to dry
and cool in the steam sterilizer before they are handled to avoid
contamination and thermal injury.
• Cooling items must not be placed on solid surfaces since
condensation of vapor inside the pack may result leading to
rusting.
• Packaged or unpackaged items must never be dried by opening
the door of the steam sterilizer before the drying cycle is
completed.
• Unwrapped critical instruments must be used immediately and
not stored after completion of the sterilizing process.
Checking the completed load:
qCheck the pressure, temperature and time on the steam
sterilizer's and compare them to the recommended values.
q If any reading is outside its specified limits, the sterilization
cycle must be regarded as unsatisfactory (regardless of results
obtained from chemical indicators) and the sterilizing cycle
should be repeated.

qIf the second cycle is

unsatisfactory, the steam
sterilizer must not be used
until the problem has been
fixed by the device technician.
qThe device logs and printouts
must be retained for
inspection and monitoring.
A- High temperature/pressure sterilization
2-Chemical vapor pressure sterilization (chemiclave)

vSterilization occurs by chemical vapor under pressure

vIt operates at 131ºC and 20 lbs pressure with a cycle time

about 30 minutes.

vThey are used with prescribed chemicals vapor as

(aldehyde, alcohol, acetone or combination).
Advantages of chemiclav:

i. Carbon steel, other corrosion sensitive burs and

instruments are said to be sterilized without rust or
corrosion.

ii. It is rapid and efficient.

iii. Items dry quickly after finishing the cycle.

Disadvantages:

1. Items sensitive to elevated temperatures will be

damaged.
2. Instruments must be lightly packaged in bags
obtained from manufacturer.
3. Routine use of biological spore test monitoring strips
to confirm heat penetration of heavy packs before using
them.
4. It requires the use of a special solution.
5. It emits odor which some find irritating and may
require strict precautions as in case of aldhyde.
*