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Contents lists available at ScienceDirect

Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Review

Autoclave sterilization of dental handpieces: A literature review

Jun-Ichi Sasaki, Satoshi Imazato*
Department of Biomaterials Science, Osaka University Graduate School of Dentistry, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: The present review aimed to investigate autoclave sterilization of dental handpieces based on
Received 14 June 2019 available studies.
Received in revised form 20 July 2019 Study selection: The sterilizing efficiency of dental handpieces with autoclave is mainly affected by the
Accepted 26 July 2019
types of apparatus (N, B, and S), the packaging with sterilizing pouch, cleaning, and lubrication. These
Available online xxx
subjects were reviewed based on the in vitro experimental studies.
Results: Dental handpieces can be sterilized, including inactivation of heat-resistant bacterial spores, with
Keywords:
type B or type S sterilizers, regardless of the use of a sterilization pouch. In contrast, although type
Dental handpiece
Autoclave
N autoclaves are capable of sterilization of general bacteria such as Streptococcus salivarius even in a
Sterilization sterilization pouch if instruments are washed beforehand, complete sterilization of the wrapped
Cleaning handpiece is not always achieved. Therefore, to achieve sterilization efficiency with type N autoclaves,
Lubrication processing without any packaging is recommended. As regards cleaning of handpiece, although
contamination decreases with irrigation and wiping of handpieces, all reports concluded that these
treatments alone do not achieve complete decontamination of reusable handpieces.
Conclusion: Although type B and type S autoclaves allow us to sterilize the dental handpieces, it is
important to realize that complete sterilization of the handpiece is not always achieved by type
N autoclave. Understanding autoclave processing of handpieces is essential for dental practice to deliver
the safe dental care.
© 2019 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction freewheeling creates negative pressure within the turbine,

In Spaulding’s classification, dental handpieces are catego-
rized with surgical instruments as critical devices requiring
sterilization for each patient [1]. This requirement is based on the
“Standard Precaution” advocated by the Centers for Disease
Control and Prevention in 1996 [2,3]. According to the preventive
policy of the “Standard Precaution,” blood, body fluids (except for
sweat), waste, wounded skin, and mucosa of all patients, with or
without infectious disease, are assumed to be infectious; this
assumption prevents infection of other patients and medical
professionals [4,5].
In general, dental handpieces are difficult to sterilize and are
likely to be contaminated with the above-mentioned infectious
materials [6]. Dental handpieces contain many small parts and
long narrow lumens [7]. In addition, the dental air turbine gains
torque by applying compressed air to the rotor; the rotor spins for a
while after air outflow because of the inertial force [8,9]. This
* Corresponding author at: Department of Biomaterials Science, Osaka University
Graduate School of Dentistry, 1-8 Yamadaoka, Suita, Osaka 565-0871, Japan.
E-mail address: imazato@dent.osaka-u.ac.jp (S. Imazato).
resulting in uptake of contaminants (e.g. saliva and blood), the
so-called suck-back effect [10,11]. In the micromotor handpiece
(e.g. straight and contra-angle), compressed air is supplied during
tooth cutting and negative pressure is not generated within the
handpiece. However, during surgical treatment, the air supply is
shut off from the dental unit and the driving gears act like a
pump, resulting in introduction of contaminants to the inner
handpiece [12,13].
Many studies on sterilization of dental handpieces have been
performed to evaluate the application of moist heat (steam), dry
heat, boiling, ethylene oxide gas, ultraviolet, bactericidal agents,
and other sterilization methods [14–17]. Currently, autoclave
sterilization, which is steam under pressure, prevails in medical
and dental fields. Established autoclave protocols have the benefits
of low costs, small footprint (bench-top units), short processing
time, minimal damage to handpieces, and high reliability of
sterilization [18–20].
Autoclave sterilization is achieved by exposing microbes to
saturated water vapor under high pressure and high temperature
inside an enclosed chamber [21]. There are three types of bench-
top autoclave. However, few studies have compared the steriliza-
tion efficiency of different autoclave types for dental handpieces.

https://doi.org/10.1016/j.jpor.2019.07.013
1883-1958/ © 2019 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: J.-I. Sasaki, S. Imazato, Autoclave sterilization of dental handpieces: A literature review, J Prosthodont Res
(2019), https://doi.org/10.1016/j.jpor.2019.07.013
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Table 1. Classification of bench-top autoclave sterilizer.
Class Air removal Sterilizing object
Type B Vacuum deaeration Any materials including
packaged,
hollow, and porous
structure
Type S Manufacturer's Device and instrument
specification designated by
manufacturer
Type N Passive displacement Unpackaged, solid,
with steam and non-porous materials
Furthermore, most dentists are unable to sterilize handpieces
appropriately because they do not learn much about autoclaves
during or after their dental training. Ideally, dentists and dental
hygienists should understand the characteristics of each type of
autoclave, operative procedures, and validation for sterilization, as
well as proper handling of sterilized handpieces. The present
review aimed to investigate autoclave sterilization of dental
handpieces based on available studies.
2. Autoclave classification
Bench-top autoclaves are categorized according to the method
of removing air from the chamber: type N, B, and S [22–24]
(Table 1). Type N autoclaves are designed only for non-wrapped
solid instruments. In contrast, type B autoclaves are considered
appropriate for sterilization of all heat-stable materials with or
without use of a sterilization pouch. Sterilization pouches, which
are constructed from porous paper and sealed before sterilization,
are designed for use in vacuum autoclaves. Therefore, type
B autoclaves are recommended for handpiece sterilization to
avoid cross-infection. However, type N autoclaves remain widely
used in many countries, including Japan and the UK [24].
3. Effects of autoclave treatment
3.1. Validation of sterilization
Sterilization efficiency can be evaluated with a chemical
indicator (CI) or biological indicator (BI); details of these indicators
are described in ISO 11140 (CI) [25] and ISO11138 (BI) [26,27],
respectively. Briefly, a CI uses an appropriate indicator (e.g. Bowie–
Dick test, Helix test) to confirm sterilizing conditions such as
penetration of the sterilizer (e.g. steam or ethylene oxide gas),
temperature, and exposure time. However, sterility of the treated
materials is not guaranteed with the CI protocol.
BI uses specific indicator endospores that are highly resistant to the
employed sterilizing process. Spores of Geobacillus stearothermophilus,
which is a well-known heat-resistant bacterium, are most widely
used for BI in autoclaves [28]. This system is commercially available
as self-contained kits, strips, and suspensions containing spores. BI
is considered a reliable indicator to validate the sterilization process
and sterility of treated materials.
3.2. Type B autoclaves
One study evaluated the sterilization efficiency of type B
autoclaves with both CI and BI [29]. Air turbines and straight
surgical handpieces were sealed in sterilization pouches then
subjected to type B autoclave treatment. In that study, none of the
handpieces had bacteria according to the BI; however, a few of the
CIs inserted in the turbine head showed sterilization fails (n = 2/
304). Anderson et al. [30] sterilized dental air turbines contami-
nated with G. stearothermophilus and Streptococcus salivarius with a
Please cite this article in press as: J.-I. Sasaki, S. Imazato, Autoclave sterilization of dental handpieces: A literature review, J Prosthodont Res
(2019), https://doi.org/10.1016/j.jpor.2019.07.013
type B autoclave and using sterilization pouches. The researchers
also tested the effects of cleaning and lubricating handpieces
before autoclave sterilization. No bacteria were detected on the
turbines after type B autoclave treatment, regardless of whether
handpieces were washed beforehand.
Larsen et al. [31] reported the sterilizing effects of type
B autoclaves according to processing time. In that study, air
turbines inoculated with G. stearothermophilus or S. salivarius were
treated with a type B autoclave for 6 min or 20 min, after which
bacterial survival inside the handpieces was evaluated.
G. stearothermophilus was detected in the turbine chamber after
6 min of autoclave treatment, but there were no surviving bacteria
after 20 min of processing. When S. salivarius was introduced to the
water channel inside the turbine, surviving bacteria were obtained
after 6 min of autoclave treatment but not after 20 min. When the
turbine wheel was inoculated with S. salivarius, no surviving
bacteria were detected after either 6 or 20 min of treatment. These
results indicate the importance of processing time, even with use
of type B autoclaves.
3.3. Type S autoclaves
One study evaluated the efficiency of type S autoclaves in
sterilizing low-speed handpieces [16]. In that study, a slip
containing G. stearothermophilus was inserted in the handpiece,
which was then sterilized in a type S autoclave. The results showed
that complete sterilization was achieved with a processing time of
105 s, regardless of whether a sterilization pouch was used.
3.4. Type N autoclaves
In the report described above [29], the sterilizing effects of type
N autoclaves was also evaluated with CI and BI. In the BI test,
G. stearothermophilus was detected in the air channel of the air
turbine (n = 1/504) and in the chuck lever of surgical straight
handpieces (n = 8/504). In addition, one air channel of an air
turbine (n = 1/504) and a few couplings of straight handpieces
(n = 4/504) failed in CI tests. These findings indicate that type
N autoclaves are able to sterilize almost all components of
handpieces, but not completely, and that failure of sterilization
may occur in the small lumen structure, even when sterilization
pouches are not used (Table 2).
In the experimental study of Anderson et al. [30], air turbines
were inoculated with G. stearothermophilus or S. salivarius (n = 12);
half of the handpieces with S. salivarius were then washed with a
manufacturer-recommended spray. These handpieces were sealed
in autoclave pouches and processed in four different type N
autoclave models (A–D), after which the presence of bacteria inside
the handpieces was evaluated. Surviving G. stearothermophilus was
detected in six turbines from autoclave A, in three from B, in one
from C, and in two from D. Regarding the S. salivarius-inoculated
turbines, bacteria were detected from two autoclave models when
spray washing was not performed; however, there were no
surviving S. salivarius in any of the turbines that were washed
before autoclaving. These findings indicate that sterilization
efficiency differs among models within the type N autoclave
category. In addition, conventional bacteria, excluding heat-
resistant bacteria, can be destroyed with a type N autoclave with
adequate prior washing of handpieces (Table 2).
Murai et al. [32] reported the sterilization efficiency of type N
autoclaves by using a self-built handpiece model and CI. In that
study, head parts and inner channels of handpieces were fixed with
epoxy resin to one side of a stainless-steel cylinder; the other side
was sealed. This model, containing the CI, was packed in a
sterilization pouch and processed with a type N autoclave. The
researcher found that the CI, which evaluated saturated steam,
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Table 2. Sterilizing efficacy of type N autoclave for dental handpieces.

Handpiece Packaging Washing Indicator Bacteria Failure (parts) Ref.

Air turbine – / BI / 1/504 [29]
(distal air channel)
Air turbine – / CI / 1/504 [29]
(distal spray channel)
Straight handpiece – / BI / 8/504 [29]
(chuck lever)
Straight handpiece – / CI / 4/504 [29]
(coupling)
Air turbine + / / G. stearothermophilus 12/48 [30]
(turbine chamber)
Air turbine + – / S. salivarius 7/24 [30]
(turbine wheel)
Air turbine + + / S. salivarius 0/24 [30]
(turbine wheel)
Self-built model + / CI / not detected [32]

exposure time, and temperature, showed the acceptance sign. The
author concluded that saturated steam penetrated via a thin water
channel to the hollow cylinder and achieved adequate sterilization
to pass the CI test (Table 2).
4. Handpiece wrapping and storage
Regarding the handling of unwrapped handpieces after
sterilization, no studies have evaluated recontamination after
autoclave treatment. However, handling of unwrapped dental
instruments is described in detail in the guideline issued by the UK
government [24]. According to this guideline, clean instruments
such as forceps and gloves should be used to aseptically wrap the
sterilized instruments in sealed view packs after autoclave
treatment. The date by which sterilized instruments must be
used or must be subjected to further sterilization should be clearly
indicated on the packs. Packaging the sterilized instruments
should be performed on a dry open bench without dust or aerosol.
After autoclave treatment, handpieces should be dried with
disposable lint-free cloths, which should be replaced after each
sterilizer load. The wrapped instruments can be stored up to 12
months in a clean dedicated area if packaging remains intact.
Unwrapped handpieces should be used within 24 h in private
clinics, even when they are transported and stored in a way that
minimizes contamination. In addition, autoclave sterilization
should be repeated for unwrapped instruments at the end of
the work day or at the beginning of the next work day, regardless of
whether the instruments have been used.
6. Conclusion
Dental handpieces can be sterilized, including inactivation of
heat-resistant bacterial spores, with type B or type S sterilizers,
regardless of the use of a sterilization pouch. In contrast, although
type N autoclaves are capable of sterilization of general bacteria
such as S. salivarius even in a sterilization pouch if instruments are
washed beforehand, it is important to realize that complete
sterilization of the handpiece is not always achieved. It is noted in
the UK guideline that use of type N autoclaves is not appropriate
for wrapped instruments. Therefore, to achieve sterilization
efficiency with type N autoclaves, which are still widely in use,
processing without any packaging is recommended. Further
studies are needed to establish comprehensive and detailed
autoclave protocol for handpieces to promote delivery of safe
dental care.
Conflict of interest statement
The authors declare no potential conflicts of interest with
respect to the authorship and/or publication of this article.
Declarations of interest
None.
Acknowledgments

5. Effects of cleaning and lubrication for autoclave treatment
Lubrication before autoclave treatment is thought to prevent
clogging and extend the useful life of handpieces [33]. However, some
studies have reported that residual lubricant prevents infiltration of
steam and hampers sterilization of handpieces [34–36]. Therefore, it is
strongly recommended to follow the manufacturer’s instructions
regarding the use of lubrication.
As for the effect of washing handpieces, reports show that
irrigation inside the handpiece significantly decreases contamina-
tion and number of bacteria [37,38]. Wiping the exterior with 70%
ethanol [39] or disinfectant [38,40] also effectively reduces
contamination. The UK guideline [24] recommends using specific
equipment, a washer–disinfector, to wash handpieces. Although
contamination decreases with irrigation and wiping of handpieces,
all reports concluded that these treatments alone do not achieve
complete decontamination of reusable handpieces. Therefore, we
reconfirm that dental handpieces should be sterilized in an
autoclave for each patient.
This work was supported by the Japanese Dental Science
Federation (JDSF-DSP2-2018-107-1).
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