ASEPSIS AND STERILIZATION

IN ORAL AND MAXILLOFACIAL SURGERY

Dr Ahmed Alkhutari

TERMS

Sterile-absence of all microorganisms including bacteria, spores and viruses.

Asepsis- freedom from infection or the absence of microorganisms that cause diseases.
Sepsis- generalized reaction to pathogenic microorganism which is evident clinically by signs of
inflammation & febrile conditions
Aseptic Techniques-practices that restrict microorganisms in the environment, equipment,
supplies & prevention of the normal body flora from contaminating the surgical wound. (Method
by which contamination with microorganisms is prevented).
Contamination-introduction of microorganisms to a sterile field.
Antiseptics-substances that renders microorganisms on living tissue inactive by preventing their
growth. Used to disinfect body surfaces, skin & tissue. Inhibits the growth of endogenous bacteria.
(Combat sepsis)
Disinfection-process by which renders inanimate objects free of pathogenic bacteria.
Disinfectants-agents that kill all growing or vegetative forms of microorganisms thus completely
eliminating them from inanimate objects.

STERILIZATION

Sterilization-process by which all living microorganisms both pathogenic & non-pathogenic

including spores are killed
Sterilization is a procedure by which we make an instrument or surface free from all vegetative
bacteria, spores, fungi, including the viruses. This can be achieved by:
• Physical methods: Dry heat, moist heat, UV light, ionizing radiations, etc.
• Chemical methods: Formaldehyde, phenolics, quaternary ammonium compounds,
chlorhexidine, sodium hypochlorite, ethylene dioxide, glutaraldehyde, etc.
Dry Heat Sterilization
Heat is the most reliable method of sterilization. The moist heat is more effective than dry heat.
Open Flaming

The instruments are held over the open spirit flame. This method is simple, not requiring any
special equipment. It is particularly useful in villages, domiciliary services or in emergency
when other methods are not available. The large instrument trays, surgical trolley tops can be
disinfected with this means. However, it is no more practiced in the clinical practice due to its
unreliability

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Hot Air Oven

This is the means of dry heat sterilization. This method is widely used for the articles like
anhydrous oils, petroleum products, talcum powder, etc. which cannot be penetrated by steam.
The conventional ovens are electrically heated and a blower forces the hot air in motion around
the items to hasten up the heating and to ensure uniform temperature in all the corners of the
oven. The early models attained the temperature of 160° to 170°C for 2 hours. The fast table top
models attain the temperature of 190° to 204°C with a total cycle time of 6 minutes for
unwrapped items and 12 minutes for the wrapped items.

Table: Time, temperature cycle in an oven

temperature time

121°C 6-12 hours

140°C 3 hours

150°C 2/ hours

160°C 2 hours

170°C 1 hours

Articles that can be sterilized

Metallic instruments, powders, oils, grea-ses, culture media and glass articles.
Advantages
• Does not corrode the instruments.
• It is simple.
Disadvantages
• It is time consuming
• Sharp instruments are rendered dull and brittle
• Rubber gloves, plastic, PVC rubber articles cannot be sterilized.

Moist Heat Sterilization

The moist heat is more effective means of sterilization than the dry heat. The methods of using
moist heat as a means of sterilization are:

Boiling

The temperature of boiling water does not rise above 100°C (212°F) and thus, only vegetative
microorganisms are killed and the bacterial spores may sur¬vive this procedure. Before the
instru¬ments are put in a boiler, it is desirable to clean all the instruments of dried, crusted
secretions, blood and rust as they tend to prevent the pene tration of the heat and thus, render

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the process of sterilization ineffective. It is achieved by thorough cleansing of the instruments
by washing, scrubbing, use of fat solvents and ultrasonic cleaning.

The instruments to be sterilized are dipped in boiling water for a period of one hour. Sodium
carbonate (2%) may be added to the water for alkalinization which elevates the boiling point of
water, reduces sterilization time and prevents corrosion of instruments by reducing O2 content
of water. Earlier boiling was a method of choice, however, it must be remembered that it is only
intermediate level disinfection and its reliability is doubtful in this era of HIV and Hepatitis.

Articles that can be sterilized:

• Surgical instruments
• Catheters
• Syringes, needles.
Advantage
It is simple and economical.
Disadvantages
• Not reliable
• Instruments tend to get corroded
• Time consuming
• Sharp instruments tend to get dull.

Autoclaving
This is the means of moist heat sterilization. It is a method of choice for sterilization of
instruments as it reliably eliminates even resistant, spore forming microorganisms, fungi,
viruses, along with vegetative microorganisms. It works on the principle of 'steam under
pressure'. It provides moist heat in the form of saturated steam under pressure. The pressure
increases the boiling point of water. Roughly for every 5 lbs. pressure, the boiling point of water
rises by 10°C by increasing the latent heat of energy for boiling of water. Hence, at 15 lbs.
pressure the boiling point of water rises to 121°C.

Table2: Time, temperature and pressure cycle in an autoclave

Pressure temperature time

15 psi 121°C 30 minutes

20 psi 134°C 3-5 minutes

(Flash method)

Mechanism of action

The steam is the mixture of heat and water vapor. When it comes in contact with any cool
surface, it gets condensed and heat is released from water. This heat is taken up by the surface
it comes in contact with. The heat goes on penetrating in the deeper layers of the object. Hence,
the steam must come in contact with the objects that are to be sterilized and thus, the objects

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must not be sealed in plastic wrappers or in the non-porous metallic containers. The steam and
the air move in vertical direction and therefore the movement will be quicker and thereby the
penetration of the steam into the material will also be better if the articles are placed vertically
in the autoclave.

Articles that can be sterilized

Instruments, gauze, cotton, linen, needles, syringes, catheters, drains, auto- clavable hand
pieces, gloves, etc.
Articles that cannot be sterilized
Powders, oils, greases, thermolabile material like electrical cords of micro-motors, fiberoptic
cable, etc.
Advantages
• Simple
• Economical
• Reliable.
Disadvantages
• Tends to corrode the instruments
• Makes sharp instruments dull.

Chemiclaving
It is also called chemical vapor sterilization. A combination of formaldehyde, alcohols, acetone,
ketones and steam at 138 KPa (combination available commercially) is used.

Cold Sterilization
Articles to be sterilized are immersed in the chemicals for achieving sterilization. The commonly
used agents for chemical sterilization are absolute alcohol, carbolic acid 2 percent, glutraldehyde
2 percent (Cidex), formaldehyde, chlorhexidine gluconate, ethylene trioxide (ETO), etc.
Articles that can be sterilized
Sharp instruments like scissors, blades and suturing needles.
The following articles can be sterilized in ETO chamber, as immersion in liquids may spoil
them.
• Splints
• Templates
• Handpieces
• Fibrooptic cables
• Micromotor cords, etc.
Articles that cannot be sterilized
Gauze, cotton, gloves, indwelling catheters, syringes, hypodermic needles, etc.
Advantages
• Simple
• Thermolabile articles can be sterilized
• Does not make sharp instruments dull.
Disadvantages
• It is not cost effective
• It tends to corrode the instruments

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• It is time consuming.
• The residue of chemicals may be carried to the tissues along with the instruments during
the surgery, which can evoke undesirable tissue reactions.

Antiseptics and disinfection

An antiseptic can be defined as a nontoxic disinfectant that can be applied to the skin or living
tissues and has the ability to destroy vegetative compounds such as bacteria by preventing their
growth. Examples of antiseptics include:
■ Povidone-iodine.
■ Proflavin.
■ Chlorhexidine.
Povidone-iodine comes in a wide range of products including antiseptics, skin preparations and
mouthwashes. The solution used for wound care is the aqueous solution that contains 1% iodine.
It is available in ointment and spray form and is impregnated into a dressing (e.g. Inadine).
Povidone-iodine has been shown to be effective against MRSA, and to date there does not appear
to be resistance to it. It is also effective against other bacteria and their spores, viruses and fungi.
Because of this, iodine has replaced most topical antibiotics. The main disadvantage is that
patients may be or may become sensitive to iodine, and it should be used only in the short term.
It should also not be used on large wounds because absorption of iodine may occur, and the
iodine is also destructive to human cells (although less than to pathogens). The alcoholic solution
is an irritant to wounds and dangerous on the face near the eyes; it is also a fire hazard and is
used much less frequently nowadays.

Chlorhexidine is a broadly active antiseptic that is used as an alternative to iodine in allergic

individuals and can be used for skin preparation and ‘scrubbing up’. It is unusual in that when
used in the mouth it binds to both tooth enamel and epithelial cells and leaches out over time,
thus providing a longer-acting effect. This may account for the evidence that suggests
chlorhexidine-containing mouthwashes are more effective than others in controlling oral
bacterial diseases.

Hand disinfection
‘Scrubbing up’ should be performed for each case. Fingernails should be kept short and
jewellery removed. Gloves are worn after drying. Various disinfectants are available.
Commonly used ones are:
■ 4% chlorhexidine gluconate (Hibiscrub, Halascrub).
■ 7.5% povidone-iodine (Betadine).
■ 2.5% chlorhexidine in 70% alcohol (Hibisol) - may be used as an alternative between cases
as long as the hands have been thoroughly scrubbed for the first case.

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■ 0.5% chlorhexidine solution - can be used as a mouth rinse (for the patient) before oral
surgery.

Cleaning wounds
- 'the solution to pollution is dilution'
Unfortunately, but unsurprisingly, it has been shown that all these antiseptics inhibit fibroblastic
activity and therefore interfere with healing. Their use in cleaning infected wounds is not
essential because the most important factor is the volume of solution used. Sterile saline in
abundance is quite adequate, although a diluted povidone-iodine solution used both to scrub
mechanically and irrigate ‘dirty’ wounds is commonplace.

Antiseptic dressings Iodine-based medicaments

Whitehead’s varnish is a mixture of iodoform, benzoin, storax, balsam of tolu and solvent ether.
It is used as an antiseptic dressing in the treatment of dry socket, packing marsupialized cysts
and as a postoperative dressing after maxillectomy. Dressings may be left in place for 2 weeks
without becoming infected. Alternatively, iodine can be mixed with bismuth to form bismuth
iodoform paraffin paste (BIPP). This can be applied to ribbon gauze and used in packing the
nose or almost any other cavity. Iodine has a disinfectant action with organic tissue; however, it
is also an irritant and may stimulate granulation tissue formation.

Commonly used dressings

Traditional dressings (e.g. gauze and Gamgee) - these are useful as secondary dressings to help
to control exudate.
Low adherent dressings (e.g. Mepitel, Melolin, Release, Skintact) - these are useful on wounds
that have a low exudate, in securing skin grafts or on burns or abrasions. Some are silicone
polymers that may improve scar quality.
Alginate dressings (e.g. Sorbsan, Kaltostat) - these are dry absorbent dressings made from
seaweed. The dressing absorbs exudate from the wound and becomes a gel. Alginates are also
useful as haemostats. They should not be used on dry wounds.
Charcoal dressings (e.g. Actisorb Plus) - these contain activated charcoal, which is effective in
absorbing chemicals released from fungating, smelly and necrotic wounds. Actisorb Plus also
contains silver, which helps to reduce bacterial growth.
Foams (e.g. Lyofoam, Cavicare) - these are synthetic dressings of hydrophilic polyurethane that
absorb wound exudate and maintain a moist wound healing environment. They can be used on
moderately to heavily exudating wounds that are healthy and granulating.
Hydrocolloids (e.g. Granuflex, Tegasorb) - these consist of a hydrocolloid base made from
gelatine, cellulose and pectins. They are completely occlusive and provide a moist wound

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healing environment. Fluid from the wound is absorbed into the dressing and forms a gel. These
dressings are useful on necrotic, sloughy and granulating wounds.
Enzyme preparation (e.g. Varidase) - this contains two enzymes (streptokinase and strep-
todornase) and is used to debride wounds, especially those with a necrotic eschar.
Hydrogels (e.g. Intrasite Gel) - these dressings are made up of a copolymer starch and have high
water content. They can be used to debride necrotic tissue or sloughy, granulating and
epithelializing wounds.
Impregnated dressings (e.g. Jelonet and Inadine)
- Jelonet is woven cotton that is impregnated with paraffin. It is commonly used on minor
burns, abrasions, split-thickness skin grafts and donor sites. Inadine is made of rayon mesh
impregnated with 10% povidone-iodine. The iodine is released directly onto the wound.
Vapour-permeable films (e.g. Tegaderm, Opsite)
- these are semipermeable, adhesive, film dressings that prevent evaporation of water from
the wound. They should be used only on superficial low exudating wounds. These dressings can
be useful in the prevention of pressure sore formation over bony prominences by reducing
friction.
Antibacterials (e.g. Flammazine cream) - Flammazine contains silver sulphadiazine 1% and is
a topical broad-spectrum antibacterial that inhibits the growth of nearly all pathogenic bacteria
and fungi in vitro. It is particularly effective against Pseudomonas and S. aureus. It is widely
used in the treatment of burns.
Haemostatic agents (e.g. Surgicel, Lyostypt) - these are forms of oxidized cellulose that promote
clotting. Flowseal is fibrin foam that is effective on bleeding bone ends.
Glues - a number of fibrin based tissue glues can be used on skin wounds and (as a spray or
drops) to stick grafts or flaps to concave wounds.
Vac-Pacs - these are basically adherent dressings that allow the generation of a vacuum
(negative) pressure within the sealed area. They promote healing to a sometimes remarkable
extent.
Mouthwashes
■ Chlorhexidine mouthwash (Corsodyl) is bactericidal. It may be helpful in ‘at risk’ patients
(e.g. osteonecrosis) by reducing the number of bacteria inoculated into the circulatory system if
it is used before surgery. The dose is 10 mL rinsed for 1 minute and then expectorated.
■ Hot salt water mouthwashes are often advised following surgery. They are helpful in
keeping the mouth clean, provide some pain relief and are cheap.
Benzydamine (Difflam) may be used to relieve the pain associated with oral ulcers or radiation
mucositis. The dose is 10 mL twice daily for up to 1 week.

Methods designed to limit the spread of hepatitis viruses from infected patient to other
patients
• Use disposable materials.
• Disinfect surfaces.
A. With halogen compounds:

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1. Iodophors
2. Hypochlorite (bleach)
B. With aldehydes:
1. Formaldehyde
2. Glutaraldehyde
• Sterilize reusable instruments.
A. With heat
B. With ethylene oxide gas
• Use disposable materials.
From Infected Patient to Dental Staff
• Learn to recognize individuals likely to be carriers.
• Use barrier techniques (e.g., gloves, face-mask, and eye protection) during surgery, when
handling contaminated objects, and during cleanup.
• Promptly dispose of sharp objects into well-labeled protective containers.
• Dispose of needles immediately after use or resheathe in-use instruments.
• Use an instrument to place a scalpel blade on or take one off a blade handle.
• Ensure hepatitis B vaccination of dental staff.

Needle stick Injury

Measures for Prevention
This can be prevented by: (i) ensuring that the needles and surgical blades are sheathed/covered,
when not in use, (ii) keeping full control of sharp instruments; and retaining full concentration
while handling such instruments, (iii) keeping gloved fingers behind the cutting edges of
surgical blades and elevators or the points of probes or needles, (iv) adequate retraction of tissues
with appropriate instruments, (v) placing needles in sharp safe box, (vi) taking care when
clearing away the surgical sharps, wires, etc. (vii) overgloving or using double gloves, whenever
indicated.

Postaccidental Management—Chemo-prophylaxis
The measures to be undertaken are as follows: (i) remove the gloves, (ii) wash the site of injury
under running water with soap and water, (iii) avoid scrubbing; and encourage bleeding and
then protect, (iv) it is controversial, whether or not, to apply antiseptic preparations like spirit or
povidone iodine. Some workers do not advise to use antiseptic preparation, as their effects on
local defenses are not known, (v) inform the patient about the incident,
(i) usually, it is necessary to take blood specimens of both the patient and the injured person;
and tested for HBV and HIV.
In case, the patient is seropositive, has AIDS, or refuses the test, the health care workers (HCWs)
should be:
1. Counseled about the risks of infection and evaluated clinically and serologically as soon as
possible after exposure. A baseline HIV test should be carried out immediately since
seroconversion will not have occurred immediately after injury.

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2. Advised to report and seek medical evaluation for any febrile illness that may occur within
12 weeks of exposure.
3. The HIV test should then be repeated approximately 6 to 12 weeks after contamination,
and on a periodic basis if seronegative.
4. Advised to follow recommendations for preventing transmission of HIV infection.
5. During this period, advise from HIV counselors is of utmost importance; regarding
domestic relations and procedures at workplace.
6. The practitioner should be immediately evaluated by a physician.
If the patient is known or suspected HBV carrier, the prophylactic requirement will depend upon
the immune status of the clinician. Those clinicians:
(i) who never had vaccination should receive hepatitis B immunoglobulins (HBIg) within 48
hours of exposure and a course of HB vaccination should begin as soon as possible, and (ii)
those who have been vaccinated, the management, would much depend upon, the antibody
response. If the antibody titer is more than 100 mU/ml within the previous year, no further action
is necessary. If blood testing was not done within the year, or, if there is low antibody titer, a
booster dose of vaccine, followed by retesting of antibody titer may be necessary. Those who
fail to respond to the vaccine should be given protection with HBIg.
Presently, there is no prophylaxis for HCV infection. The management, would consist of
monitoring liver functions and testing for anti-HCV antibodies. There is little evidence to
suggest that such cases may respond favorably, if treated at the earliest sign of infection with
interferon-a.