Efficacy of Various Decontamination Methods and Sterilization

on Contaminated and Inoculated Diamond-Coated Burs

Nicole Wirth, Capt, USAF, DC

Resident, Air Force Postgraduate Dental School
Uniformed Services University of the Health Sciences Postgraduate Dental College
Advanced Education in General Dentistry Residency
1615 Truemper St
Joint Base San Antonio - Lackland, TX 78236

Daniel Savett, Col, USAF, DC

Director, USAF Dental Research and Consultation Service (DRCS)
Assistant Professor, Uniformed Services University of the Health Sciences Postgraduate
Dental College 3698 Chambers Pass, Bldg 3610
Joint Base San Antonio, Fort Sam Houston, TX 78234

Wen Lien, Col, USAF, DC

Director, Dental Materials Evaluation and Testing
Associate Professor, Uniformed Services University of the Health Sciences Postgraduate
Dental College
USAF Dental Research and Consultation Service (DRCS) 3698
Chambers Pass, Bldg 3610
Joint Base San Antonio, Fort Sam Houston, TX 78234

Michael Crabtree, Col, USAF, DC

Director, Endodontics
Associate Professor, Uniformed Services University of the Health Sciences Postgraduate
Dental College
Air Force Postgraduate Dental School
Advanced Education in General Dentistry Residency
1615 Truemper St
Joint Base San Antonio - Lackland, TX 78236

Kraig S. Vandewalle, Col (ret), USAF, DC

Director of Dental Research
Professor, Uniformed Services University of the Health Sciences Postgraduate Dental
College
Air Force Postgraduate Dental School
Advanced Education in General Dentistry Residency
1615 Truemper St
Joint Base San Antonio - Lackland, TX 78236

1
 The objective of this study was to evaluate the effectiveness of various
decontamination methods and subsequent sterilization on contaminated and inoculated
diamond-coated burs. Diamond-coated burs and extracted human molars were sterilized
with a steam sterilizer. Enamel and dentin from the extracted teeth were abraded utilizing
diamond-coated burs using a high-speed handpiece. The burs were subsequently
inoculated with one of the following microorganisms: Enterococcus faecalis ATCC
19433, Staphylococcus aureus ATCC 6538, Pseudomonas aeruginosa ATCC 15442 or
Geobacillus stearothermophilus ATCC 7953. Twenty-four hours after inoculation, the
burs were subjected to various cleaning treatments, sterilized, and then cultured for
bacterial contamination. The number of CFU/mL was determined per group. Except for
the positive control group, no CFU/mL or growth was found for all treatment groups and
for all bacterial types. In conclusion, the contaminated and inoculated diamond-coated
burs tested in this study were successfully sterilized to eliminate the tested bacteria. The
use of a cleaning stone with manual cleaning or an ultrasonic cleaner resulted in the least
amount of remaining tooth debris on the diamond-coated bur heads.

Keywords: Diamond-coated burs, cleaning, sterilization

INTRODUCTION
Dental burs are one of the most commonly used dental instruments within a dental
practice. Of those dental burs, diamond burs with their unique cutting structures are
essential dental rotary instruments used for both operative and fixed restorative dentistry
[1]. A conventional “diamond bur”, more accurately called a diamond-coated bur, is a
metal rod that is coated by galvanic deposition with diamond powder during
manufacturing. The shape of the diamond granules imbedded on the bur, resulting in its
complex surface roughness, is often a source that invites the accumulation of dental
debris, microorganisms and other materials, which in turn make diamond-coated burs
more difficult to clean and sterilize [1].
Diamond-coated burs were first introduced in the late 19th century. Depending
on the manufacturer, brand, or cost, the perception of single-use

2
versus multi-use diamond burs varies between different clinical practices and remains
controversial. In recent years, however, to eliminate any chance of cross contamination,
there has been a push to classify diamond-coated burs as single- use devices [1]. In
October of 2002, the Medical Device User Fee and Modernization Act of 2002
(MDUFMA) amended the previous Federal Food, Drug, and Cosmetic Act by providing
new regulatory requirements for reprocessed single-use devices (SUDs) [2]. This new
amendment removed the previous pre- marketed exemption for diamond-coated burs and
now requires manufacturers to provide validation data which includes cleaning,
sterilization, and functional performance [3].
Several studies have evaluated the cleaning and sterilization of endodontic files
and carbide burs, but limited research has been published investigating diamond-coated
burs. For the debridement of endodontic files, a study by Perakaki et al. found that the use
of an ultrasonic cleaner for 10 minutes was more successful in cleaning debris from the
structurally complex endodontic file than a washer disinfector [4]. Similarly, another
study found that an ultrasonic cleaner had a significant effect on the cleanliness of the
endodontic files; pre-soaking did not benefit sterilization; and, the optimum time for
ultrasonic cleaning was between 5 and 10 minutes [5]. For the debridement of carbide
burs, a 2016 case-control study found that the use of a high-pressure autoclaving session
followed by a low- pressure steam autoclave session resulted in no bacterial growth on
used carbide- fissure burs [6]. A study by Kumar et al. stated that autoclaving or
glutaraldehyde was an effective method to sterilize carbide-steel burs [7]. This was
further supported in a study by Mathivanan et al., who found that the use of autoclave and
hot air ovens were relatively the best method of bur sterilization in comparison to a glass
bead sterilizer [8]. However, these studies did not evaluate diamond- coated burs. One
study examined the effectiveness of pre-cleaning diamond- coated burs covered with a
dye and found that none of the pre-cleaning methods were effective in removing the dye
and that the diamond-coated bur head was the most frequently contaminated site on the
bur [9]. An additional study on diamond- coated burs found that none of the cleaning or
sterilization methods were

3
absolutely efficacious, but the study did not examine a combination of cleaning and
sterilization. [10].
Limited research has been published examining the efficacy of various
decontamination methods and sterilization of diamond-coated burs. In addition, no
research has been published examining the Clean-A-Diamond Mini Square (Premier,
Plymouth Meeting, PA), which is an autoclavable, reusable dressing stone that can
reportedly be used to unclog coarse- and medium-grit diamond- coated burs. Therefore,
the aim of this study was to evaluate the effectiveness of various decontamination
methods and subsequent sterilization on contaminated and inoculated diamond-coated
burs. The null hypotheses were there would be no difference between various
decontamination methods in: (1) microorganism elimination or (2) debridement of
contaminated and inoculated course diamond- coated burs.

METHODS
The Institutional Review Board at Wilford Hall Ambulatory Surgical Center,
Joint-Base San Antonio, Lackland, Texas approved this protocol (#FWH20190066N). A
total of 7 groups with 20 diamond-coated burs (5847.31.016 FG Super Coarse Flat-End
Cylinder Diamond, Brasseler, Savannah, GA) per each group were evaluated. The
diamond-coated burs along with extracted human third molars were sterilized with a
steam sterilizer (Amsco 400, Steris, Mentor, OH). Each bur was heavily contaminated
with enamel and dentin debris via abrasion for 30 seconds with a high-speed handpiece
(Forza F5, Brasseler, Savannah, GA) and water coolant. One group of burs was tested
after removal from their original packaging and did not receive any contamination with
tooth debris.
Three microorganisms: Enterococcus faecalis ATCC 19433, Staphylococcus
aureus ATCC 6538, and Pseudomonas aeruginosa ATCC 15442, were grown on trypticase
soy agar with 5% sheep blood (TSA II) and incubated (Thermo Forma Steri Cycle 370
CO2 Incubator, Thermo Fischer, Waltham, MA) at 35 +/- 2°C ambient air for 24 hours.
Geobacillus stearothermophilus ATCC 7953 was incubated at 50 +/- 2°C ambient air
for 24 hours and grown on TSA II.

4
Staphylococcus aureus and Pseudomonas aeruginosa were chosen due to their extensive
use in evaluating sterilization and disinfection procedures by the Environmental Protection
Agency [11]. Additionally, Staphylococcus aureus, Pseudomonas aeruginosa and
Enterococcus faecalis have been proven to be prevalent in hospital acquired infections
[12-14]. Geobacillus stearothermophilus has been utilized to monitor steam sterilization,
hydrogen peroxide gas plasma, and liquid peracetic acid sterilizers [15]. Inoculation
suspensions of the microorganisms were prepared by cultivating the organisms in
Trypticase Soy Broth to a concentration of approximately 1.5 x 10 8 CFU/mL, then a 1:10
dilution of the suspension was made with sterile saline resulting in an inoculum
suspension of approximately 1.5 x 107 CFU/mL. The diamond-coated burs were
inoculated (except negative control and new, unused, pre-packaged bur groups) by
immersing them in 1 mL of the inoculum suspensions. They remained in the inoculum for
10 minutes (represents the approximate amount of time the burs would be in the patient’s
mouth). The burs were then placed in a sterile container for 24 hours. After being
contaminated with enamel and dentinal debris, the burs in the negative control group were
divided into four groups with 5 burs in each group. Each bur underwent one of four
different decontamination methods with subsequent sterilization. This process was to
determine if there was outside microorganism contamination at any step during the
experiment. Table 1 outlines the various treatment methods completed per group.
The diamond-coated burs from each group were immersed in 1 mL of sterile
saline and vortex mixed (Fisher Heavy Duty Vortex Mixer, Fisher Scientific, Waltham,
MA) for 2 minutes to remove microorganisms from the bur. The saline from the positive
controls were serially diluted (1:10) and plated on TSA II. Saline from each of the
cleaning protocol groups (4-7), the negative control, and the new, unused, pre-packaged
burs were plated on the TSA II as before. E. faecalis, S. aureus, and P. aeruginosa plates
were incubated at 35 +/- 2°C in ambient air for 24 hours. G. stearothermophilus plates
were incubated at 50 +/- 2°C in ambient air for 24 hours.
After incubation, the number of colony forming units (CFUs) on the plates

5
were counted and CFU/mL recovered were calculated. The mean CFU/mL and standard
deviation was determined per group. The bur heads from Groups 4 through 7 were
examined under a light microscope (Nikon SMZ-1B, Melville, NY) at 10x magnification
and rated as none (0), minimal (1), moderate (2), or heavy (3) for level of remaining
enamel and dentin debris. Representative images of the burs were taken with a
stereomicroscope (SZX16, Olympus, Shinjuku, Japan). See Figure 1. The tooth debris
data were analyzed with statistical software (SPSS, version 25, IBM, Armonk, NY). All
the groups were analyzed with the Kruskall Wallis test (alpha = 0.05). The Mann
Whitney U test was used to make comparisons between groups. The alpha value was
adjusted to 0.008 with a Bonferroni correction because multiple comparisons were
completed simultaneously.

RESULTS
Except for the positive control (Group 1), no CFU/mL or growth was found for all
treatment groups and for all bacterial types. None of the diamond-coated burs from the
negative control group (Group 2) demonstrated any bacterial growth. Also, none of the
new, unused, prepackaged burs demonstrated any bacterial growth (Group 3). See Table
1. For remaining tooth debris, the results of the Kruskall-Wallis test found a significant
difference between groups (p=0.0001). Using the Mann-Whitney U test, there were
significant differences between all the groups (p<0.008) except between groups 5 and 7
(p=0.46). Group 4 (Median=2, IQR=1) had significantly more debris than all other
groups. Group 6 (Median=1, IQR=2) had significantly less debris than Group 4, but
significantly greater debris than Groups 5 and 7. Group 7 (Median=0.5, IQR=1) had the
lowest level of debris, but it was not significantly less than Group 5 (Median=1, IQR=1).

DISCUSSION
The complex surface structure of diamond-coated burs retains tooth debris and
may make them more difficult to sterilize than carbide burs. However, in this

6
study, there was no difference in microorganism elimination based on decontamination
method along with sterilization due to no observable growth of microorganism.
Therefore, the first null hypothesis was not rejected. A study by Sajjanshetty et al. found
that none of the individual techniques (i.e., manual scrubbing, hot air oven, glass bead
sterilizer, ultrasonic cleaner, autoclave) were absolutely efficacious on diamond-coated
burs. Of the methods tested, the autoclave was the most effective in decreasing the
colony-forming units of Streptococcus mutans [10]. In contrast, this study found that the
use of a steam sterilizer in combination with various pre-cleaning procedures resulted in
no growth of any of the four tested bacteria on coarse diamond-coated burs. Additionally,
this study reinforced the manufacturer’s claim that diamond-coated burs are sterile in
their individual packages and require no further action prior to first use.
Previous laboratory research found that an ultrasonic cleaner was successful in
reducing debris from endodontic files [4,5]. However, Gul et al. found that various pre-
cleaning methods (i.e., manual, ultrasonic, manual with enzyme, manual with ultrasonic)
were not effective in removing a dye from diamond-bur heads [9]. Comparisons to this
study are difficult because the removal of dye would be different from removing debris.
This study demonstrated significant differences based on debridement method, so the
second null hypothesis was rejected. No pre-cleaning methods were completely
efficacious at removing all the dentinal debris. The manual cleaning procedure (Group 4)
resulted in the removal of significantly less tooth debris than all the other groups with
over 70% of the burs retaining a moderate to heavy level of debris. The use of an
ultrasonic cleaner (Group 6) resulted in significantly more debris removal compared to
the manual cleaning procedure (Group 4), but significantly less debris removal compared
to the use of the manual cleaning and Clean-A-Diamond stone (Group 5) or ultrasonic
cleaning and Clean-A-Diamond stone (Group 7). The use of an ultrasonic cleaner along
with a Clean-A-Diamond stone (Group 7) resulted in the least amount of remaining tooth
debris with 96% of the burs demonstrating minimal or no remaining debris. However, it
was not significantly different from the use of manual cleaning and a Clean-A-Diamond
stone (Group 5) with 94% of the burs demonstrating

7
minimal or no remaining debris. The additional use of the Clean-A-Diamond stone
appeared to make a dramatic improvement in the decontamination of the diamond- coated
burs compared to the use of either the manual cleaning procedure or ultrasonic cleaner
alone. See Figure 2.
The disposal of a multi-use diamond-coated bur after one use may not be cost
effective. According to the manufacturer, (technical representative, Brasseler), their
conventional multi-use diamond-coated bur evaluated in this study should be used a
maximum of 12 times before discarding, but only on one patient. A pack of 5 burs is
approximately $60, and equates to approximately $12 per bur if not sterilized and re-
used. With the new single-use diamond burs, the manufacturer recommends that each bur
be discarded after only one preparation. The price of a 25 bur pack is approximately $50,
which equates to about $2 per preparation. Differences in costs will vary depending on
the manufacturer and type of bur. Cutting efficiency and lifespan is dependent on
numerous factors such as coarseness of bur, substrate material (e.g., enamel, dentin,
composite, ceramic), preparation time, and the speed and torque of the handpiece and the
amount of water spray. Limitations to this study include the use of only one type and
coarseness of a diamond-coated bur and only one cycle of debridement and sterilization.
Based on the results of this study, the increased cost and waste created through the
single use of diamond-coated burs may be unwarranted since the contaminated and
inoculated diamond-coated burs evaluated were satisfactorily debrided and sterilized after
one use. If using a diamond-coated bur multiple times, it may be the most efficacious for
practitioners to consider either utilizing the protocol outlined in Group 5 - a two-second
debridement with a Clean-A-Diamond stone followed by the manual cleaning cycle and
one cycle of steam sterilization, or in Group 7 - a two-second debridement with a Clean-
A-Diamond stone, a 15 minute ultrasonic cleaning, and one cycle of steam sterilization.
Either of these two protocols should ensure a sterile diamond-coated bur that is
reasonably free of tooth debris.

8
CONCLUSION
The contaminated and inoculated diamond-coated burs tested in this study were
successfully sterilized to eliminate the tested bacteria. The use of a cleaning stone with
manual cleaning or with an ultrasonic cleaner provided the least amount of remaining
tooth debris on the diamond-coated bur heads.

Disclaimer: The views expressed are those of the authors and do not reflect the official
views of policies of the Uniformed Services University, Department of Defense, or its
Components. The authors do not have any financial interest in the companies whose
materials are discussed in this manuscript.

REFERENCES

1. Siegel, S.C. and J.A. Von Fraunhofer, Dental Cutting: The Historical Development
of Diamond Burs. The Journal of the American Dental Association, 1998. 129(6): p. 740-
745.

2. Office of the Federal Register (Ed.). (2005). The United States Government Manual.
Volume 70, Issue188

3. Morrison, A. and S. Conrod, Dental burs and endodontic files: are routine sterilization
procedures effective? J Can Dent Assoc, 2009. 75(1): p. 39.

4. Perakaki, K., A.C. Mellor, and A.J. Qualtrough, Comparison of an ultrasonic cleaner
and a washer disinfector in the cleaning of endodontic files. J Hosp Infect, 2007. 67(4): p.
355-9.

5. Aasim, S.A., A.C. Mellor, and A.J. Qualtrough, The effect of pre-soaking and time in
the ultrasonic cleaner on the cleanliness of sterilized endodontic files. Int Endod J, 2006.
39(2): p. 143-9.

9
6. Al-Jandan, B.A., et al., Should Surgical Burs Be Used as Single-Use Devices to
Avoid Cross Infection? A Case-Control Study. Med Princ Pract, 2016. 25(2): p. 159-62.

7. Kumar, K.V., et al., Pathological evaluation for sterilization of routinely used

prosthodontic and endodontic instruments. J Int Soc Prev Community Dent, 2015. 5(3):
p. 232-6.

8. Mathivanan, A., et al., Evaluation of Efficiency of Different Decontamination

Methods of Dental Burs: An In vivo Study. J Pharm Bioallied Sci, 2017. 9(Suppl 1): p.
S37-S40.

9. Gul, M., et al., Assessment of contamination on sterilized dental burs after being
subjected to various pre-cleaning methods. J Pak Med Assoc, 2018. 68(8): p. 1188-1192.

10. Sajjanshetty, S., et al., Decontamination methods used for dental burs - a
comparative study. J Clin Diagn Res, 2014. 8(6): p. ZC39-41.

11. EPA. Efficacy Test Methods, Test Criteria, and Labeling Guidance for
Antimicrobial Products with Claims Against Biofilm on Hard, Non-Porous Surfaces
https://www.epa.gov/pesticide-analytical-methods/efficacy-test-methods-test- criteria-
and-labeling-guidance-antimicrobial Accessed 18 May 2020.

12. Javanmardi F, Emami A, Pirbonyeh N, Keshavarzi A, Rajaee M. A systematic

review and meta-analysis on Exotoxins prevalence in hospital acquired Pseudomonas
aeruginosa isolates. Infect Genet Evol 2019; 75:104037.

13. Mekviwattanawong S, Srifuengfung S, Chokepaibulkit K, Lohsiriwat D,

Thamlikitkul V. Epidemiology of Staphylococcus aureus infections and the

10
prevalence of infection caused by community-acquired methicillin-resistant
Staphylococcus aureus in hospitalized patient at Siriraj Hospital. J Med Assoc Thai 2006;
89 Suppl5:S106-117.

14. Wade JJ. Enterococcus faecium in hospitals. Eur J Clin Microbiol Infect Dis.
1997;16:113-9.

15. CDC. Sterilizing Practices: Guideline for Disinfection and Sterilization in

Healthcare Facilities (2008)
https://www.cdc.gov/infectioncontrol/guidelines/disinfection/sterilization/sterilizing
-practices.html . Accessed 18 May 2020.

11
 Group Contamination Decontamination Method Sterilization
Method
1 Positive Control Tooth debris only None None
2 Negative Control Tooth debris only Burs were divided into four groups of five, each Steam-one cycle
undergoing one of the decontamination and sterilization of steam
methods noted in Groups 4-7. sterilization✯
3 New, unused, None None None
prepackaged
4 Manual cleaning Tooth debris and One-minute rinse under cool running water Steam-one cycle
(Brasseler IFU) bacteria 10-minute immersion in a neutral-pH cleaning solution+ of steam
+
One-minute brush in the solution sterilization✯
One-minute rinse under warm water until visibly clean

5 Clean-A-Diamond Tooth debris and 2 seconds of debridement with the Clean-A-Diamond stone^ Steam-one cycle
stone & bacteria One-minute rinse under cool running water of steam
manual cleaning 10-minute immersion in a neutral-pH cleaning solution+ sterilization✯
(Brasseler IFU) One-minute brush in the solution+
One-minute rinse under warm water until visibly clean

6 Ultrasonic Cleaning Tooth debris and 15-minute sonication in an ultrasonic unit* Steam-one cycle
(Brasseler IFU) bacteria of steam
sterilization✯
7 Clean-A-Diamond Tooth debris and 2 seconds of debridement with the Clean-A-Diamond stone^ Steam-one cycle
stone & Ultrasonic bacteria 15-minute sonication in an ultrasonic unit* of steam
cleaning (Brasseler sterilization✯
IFU)
+Dawn Ultra, Proctor & Gamble, Cincinnati, OH; *1000 Pro-Sonic, Sultan Healthcare, York, PA; ✯Amsco 400; ^Mini Square,
Premier, Plymouth Meeting, PA

Table 1: Cleaning, decontamination, and sterilization methods by Group.

12
 CFU/mL (range)
Enterococcus Staphylococcus Pseudomonas Geobacillus
Treatment faecalis aureus aeruginosa stearothermophilus

Groups
Group 1 1.2-5.3 x 105 1.1-7.9 x 105 1.2-6.7 x 106 1.0-1.6 x 105

Group 2 No growth No growth No growth No growth

Group 3 No growth No growth No growth No growth
Group 4 No growth No growth No growth No growth
Group 5 No growth No growth No growth No growth
Group 6 No growth No growth No growth No growth
Group 7 No growth No growth No growth No growth

Table 2: Bacterial growth of each of the Groups.

Figure 1: Representative image of unused bur and burs with various of level of tooth
debris rated as None (0), Minimal (1), Moderate (2), or Heavy (3). After
decontamination and sterilization, each bur from Groups 4 – 7 were rated for level of
debris.

13
 Remaining Tooth Debris
100

80

60
%
40

20

0
Group 4 Group 5 Group 6 Group 7
Minimal Moderate
None Heavy

Figure 2: Level of remaining tooth debris for Groups 4 through 7.

14
Tujuan dari penelitian ini adalah untuk mengevaluasi keefektifan berbagai metode dekontaminasi
dan sterilisasi berikutnya pada diamond-coated bur yang terkontaminasi dan diinokulasi.
Diamond-coated bur dan geraham manusia yang diekstraksi disterilkan dengan alat sterilisasi
uap. Enamel dan dentin dari gigi yang dicabut dikikis menggunakan diamond-coated bur
menggunakan high-speed handpiece. Kemudian bur diinokulasi dengan salah satu
mikroorganisme berikut: Enterococcus faecalis ATCC 19433, Staphylococcus aureus ATCC
6538, Pseudomonas aeruginosa ATCC 15442 atau Geobacillus stearothermophilus ATCC 7953.
Dua puluh empat jam setelah inokulasi, bur diberi berbagai perawatan pembersihan, disterilkan,
dan kemudian dikultur untuk kontaminasi bakteri. Jumlah CFU/mL ditentukan per kelompok
selain pada kelompok kontrol positif, tidak ditemukan CFU/mL atau pertumbuhan untuk semua
kelompok perlakuan dan untuk semua jenis bakteri. Dengan demikian, dapat disimpulkan bahwa
diamond-coated bur yang terkontaminasi dan diinokulasi yang diuji dalam penelitian ini berhasil
disterilkan guna mengeliminasi bakteri yang diuji. Penggunaan batu pembersih (cleaning stone)
dengan pembersihan manual atau pembersih ultrasonik dapat menghasilkan sisa gigi yang tersisa
paling sedikit pada kepala diamond-coated bur.

Kata Kunci: diamond-coated bur, pembersihan, sterilisasi

PENDAHULUAN

Dental burs merupakan salah satu instrumen gigi yang paling umum digunakan dalam praktik
kedokteran gigi. Dari dental burs tersebut, diamond burs dengan struktur pemotongannya yang
unik merupakan instrumen rotari gigi penting yang digunakan dalam kedokteran gigi restorasi
operatif dan cekat [1]. Diamond burs konvensional atau yang lebih umum dikenal sebagai
diamond-coated bur, adalah batang logam yang dilapisi oleh galvanic deposition dengan bubuk
berlian selama pembuatan. Bentuk butiran berlian yang melekat pada bur dapat menghasilkan
kekasaran permukaan yang kompleks, seringkali menjadi sumber yang memicu akumulasi
serpihan gigi, mikroorganisme, dan bahan lain, yang pada akhirnya dapat membuat diamond-
coated bur lebih sulit dibersihkan dan disterilkan. [1]. Diamond-coated bur pertama kali
diperkenalkan pada akhir abad ke-19. Bergantung pada pabrikan, merek, atau biaya, persepsi
diamond burs sekali pakai versus multiguna bervariasi antara praktik klinis yang berbeda dan
tetap kontroversial. Meskipun demikian, dalam beberapa tahun terakhir, untuk menghilangkan
kemungkinan kontaminasi silang, ada dorongan untuk mengklasifikasikan diamond-coated bur
sebagai perangkat sekali pakai [1]. Lebih lanjut, pada bulan Oktober 2002, Medical Device User
Fee and Modernization Act of 2002 (MDUFMA) mengamandemen Undang-Undang Pangan,
Obat-obatan, dan Kosmetik Federal sebelumnya dengan memberikan persyaratan peraturan baru
untuk perangkat sekali pakai (SUD) yang diproses ulang [2]. Amandemen baru ini menghapus
pengecualian pra-pasar sebelumnya untuk diamond-coated bur dan saat ini mengharuskan
produsen untuk memberikan data validasi yang meliputi pembersihan, sterilisasi, serta kinerja
fungsional [3].

Beberapa penelitian telah mengevaluasi pembersihan dan sterilisasi file endodontik dan
carbide burs. Meskipun demikian, penelitian mengenai diamond-coated bur yang telah
dipublikasikan masih terbatas. Mengenai debridemen file endodontik, sebuah penelitian yang
dilakukan oleh Perakaki et al. menunjukan bahwa penggunaan pembersih ultrasonik (ultrasonic
cleaner) selama 10 menit lebih berhasil untuk membersihkan puing-puing dari struktur file
endodontik yang kompleks dibandingkan disinfektan pencuci (Washer disinfector) [4].
Sementara itu, penelitian lain menunjukan bahwa pembersih ultrasonik (ultrasonic cleaner)
memiliki pengaruh yang signifikan terhadap kebersihan file endodontik; pra-perendaman (pre-
soaking) tidak berguna untuk sterilisasi; dan, waktu optimal untuk pembersihan ultrasonik adalah
antara 5 dan 10 menit [5]. Lebih lanjut, mengenai debridemen carbide burs, sebuah Studi kasus-
kontrol tahun 2016 menunjukan bahwa penggunaan sesi autoklaf bertekanan tinggi yang diikuti
dengan sesi autoklaf uap bertekanan rendah tidak menghasilkan pertumbuhan bakteri pada
carbide fissure burs bekas [6]. Sementara itu, penelitian yang dilakukan oleh Kumar et al.
menunjukan bahwa autoklaf atau glutaraldehida merupakan metode yang efektif untuk
mensterilkan carbide-steel burs [7]. Hal ini sejalan dengan penelitian yang dilakukan oleh
Mathivanan et al., yang mengungkapkan bahwa penggunaan autoclave dan oven udara panas
relatif merupakan metode sterilisasi bur yang terbaik dibandingkan dengan glass bead sterilizer
[8]. Meskipun demikian, penelitian ini tidak mengevaluasi diamond-coated bur. Sebuah
penelitian mengenai keefektifan pre-cleaning diamond-coated bur yang dilapisi dengan pewarna
dan menemukan bahwa tidak ada metode pra-pembersihan (pre-cleaning) yang efektif untuk
menghilangkan pewarna; disamping itu, kepala diamond-coated bur merupakan tempat yang
paling sering terkontaminasi pada bur [ 9]. Penelitain tambahan menegani diamond-coated bur
mengungkapkan bahwa tidak ada metode pembersihan atau sterilisasi yang benar-benar efektif,
tetapi penelitian tersebut tidak meneliti kombinasi pembersihan dan sterilisasi. [10].

Penelitian mengenai keefektifan berbagai metode dekontaminasi dan sterilisasi diamond-

coated bur yang telah dipublikasikan terbatas. Selain itu, belum ada penelitian yang dipublikasi
yang meneliti Clean-A-Diamond Mini Square (Premier, Plymouth Meeting, PA), yang
merupakan dressing stone yang dapat diautoklaf dan dapat digunakan kembali yang umumnya
dapat digunakan untuk membuka sumbatan diamond-coated bur kasar dan sedang. Oleh karena
itu, tujuan dari penelitian ini adalah untuk meneliti keefektifan berbagai metode dekontaminasi
dan sterilisasi berikutnya pada diamond-coated bur yang terkontaminasi dan diinokulasi.
Hipotesis nol adalah tidak akan ada perbedaan antara berbagai metode dekontaminasi dalam: (1)
penghilangan mikroorganisme atau (2) debridemen diamond-coated bur yang terkontaminasi dan
diinokulasi.

METODE

Institutional Review Board di Wilford Hall Ambulatory Surgical Center, Joint-Base San
Antonio, Lackland, Texas menyetujui protokol ini (#FWH20190066N). Sebanyak 7 grup dengan
20 diamond-coated bur (5847.31.016 FG Super Coarse Flat-End Cylinder Diamond, Brasseler,
Savannah, GA) per masing-masing grup dievaluasi. Diamond-coated bur bersama dengan molar
ketiga manusia yang diekstraksi disterilkan dengan alat sterilisasi uap (Amsco 400, Steris,
Mentor, OH). Setiap bur terkontaminasi berat dengan enamel dan dentin debris melalui abrasi
selama 30 detik dengan high-speed handpiece (Forza F5, Brasseler, Savannah, GA) dan water
coolant. Satu kelompok bur diuji setelah dikeluarkan dari kemasan aslinya dan tidak menerima
kontaminasi dengan debris gigi.

Tiga mikroorganisme: Enterococcus faecalis ATCC 19433, Staphylococcus aureus

ATCC 6538, dan Pseudomonas aeruginosa ATCC 15442, ditumbuhkan pada agar kedelai
trypticase dengan 5% darah domba (TSA II) dan diinkubasi (Inkubator Thermo Forma Steri
Cycle 370 CO2, Thermo Fischer, Waltham, MA) pada 35 +/- 2°C udara ambien selama 24 jam.
Sementara itu, geobacillus stearothermophilus ATCC 7953 diinkubasi pada suhu 50 +/- 2°C
udara sekitar selama 24 jam dan ditumbuhkan pada TSA II.
Staphylococcus aureus dan Pseudomonas aeruginosa dipilih karena penggunaannya yang luas
dalam mengevaluasi prosedur sterilisasi dan desinfeksi oleh Badan Perlindungan Lingkungan
[11]. Selain itu, Staphylococcus aureus, Pseudomonas aeruginosa serta Enterococcus faecalis
telah terbukti lazim pada infeksi yang didapat di rumah sakit [12-14]. Geobacillus
stearothermophilus telah digunakan untuk memantau sterilisasi uap, plasma gas hidrogen
peroksida, serta sterilisasi asam perasetat cair [15]. Suspensi inokulasi mikroorganisme dibuat
dengan cara membudidayakan organisme dalam Trypticase Soy Broth dengan konsentrasi
kurang lebih 1,5 x 108 CFU/mL, kemudian dibuat pengenceran suspensi 1:10 dengan sterile
saline sehingga diperoleh suspensi inokulum kurang lebih 1,5 x 107 CFU/mL. Diamond-coated
bur diinokulasi (selain kontrol negatif dan kelompok bur baru, tidak terpakai, dan dikemas
sebelumnya) dengan merendamnya dalam 1 mL suspensi inokulum. Mereka tetap berada di
inokulum selama 10 menit (mewakili perkiraan jumlah waktu bur akan berada di mulut pasien).
Bur kemudian ditempatkan dalam wadah steril selama 24 jam. Setelah terkontaminasi dengan
enamel dan debris dentin, bur pada kelompok kontrol negatif dibagi menjadi empat kelompok
dengan masing-masing kelompok terdiri dari 5 bur. Setiap bur menjalani salah satu dari empat
metode dekontaminasi yang berbeda dengan sterilisasi berikutnya. Proses ini berguna untuk
menentukan apakah ada kontaminasi mikroorganisme dari luar pada setiap langkah selama
percobaan. Tabel 1 menguraikan berbagai metode perawatan yang diselesaikan per kelompok.

Diamond-coated bur dari masing-masing kelompok direndam dalam 1 mL saline steril

dan campuran vortex (Fisher Heavy Duty Vortex Mixer, Fisher Scientific, Waltham, MA)
selama 2 menit untuk menghilangkan mikroorganisme dari bur. Saline dari kontrol positif
diencerkan secara serial (1:10) dan dilapisi dengan TSA II. Saline dari masing-masing kelompok
protokol pembersihan (4-7), kontrol negatif, dan bur kemasan baru yang tidak terpakai dilapiskan
pada TSA II seperti sebelumnya. Pelat E. faecalis, S. aureus, dan P. aeruginosa diinkubasi pada
suhu 35 +/- 2°C di udara sekitar selama 24 jam. Sementara itu, pelat G. stearothermophilus
diinkubasi pada suhu 50 +/- 2°C di udara sekitar selama 24 jam.

Setelah inkubasi, jumlah unit pembentuk koloni (CFU) pada cawan dihitung dan
CFU/mL yang diperoleh kembali dihitung. Rata-rata CFU/mL dan standar deviasi ditentukan per
kelompok. Kepala bur dari Grup 4 hingga 7 diperiksa di bawah mikroskop cahaya (Nikon SMZ-
1B, Melville, NY) dengan perbesaran 10x dan dinilai tidak ada (0), minimal (1), sedang (2), atau
berat (3) untuk tingkat sisa email dan puing-puing dentin. Gambar representatif bur diambil
dengan mikroskop stereo (SZX16, Olympus, Shinjuku, Jepang). Lihat Gambar 1. Data sisa gigi
dianalisis dengan perangkat lunak statistik (SPSS, versi 25, IBM, Armonk, NY). Semua
kelompok dianalisis dengan uji Kruskall Wallis (alfa = 0,05). Sedangkan, tes Mann Whitney U
digunakan untuk membuat perbandingan antar kelompok. Nilai alfa disesuaikan menjadi 0,008
dengan koreksi Bonferroni karena beberapa perbandingan diselesaikan secara bersamaan.

HASIL

Selain pada kontrol positif (Grup 1), tidak ada CFU/mL atau pertumbuhan yang ditemukan untuk
semua kelompok perlakuan dan untuk semua jenis bakteri. Tak satu pun dari diamond-coated bur
dari kelompok kontrol negatif (Grup 2) menunjukkan pertumbuhan bakteri. Selain itu, tidak ada
bur baru, tidak terpakai, dan dikemas yang menunjukkan pertumbuhan bakteri (Grup 3). Lihat
Tabel 1. Untuk sisa debris gigi, hasil uji Kruskall-Wallis didapatkan perbedaan yang signifikan
antar kelompok (p=0,0001). engan menggunakan uji Mann-Whitney U, terdapat perbedaan yang
signifikan antara semua kelompok (p<0,008) selain antara kelompok 5 dan 7 (p=0,46). Grup 4
(Median=2, IQR=1) memiliki puing-puing yang jauh lebih banyak dibandingkan dengan semua
grup lainnya. Grup 6 (Median=1, IQR=2) memiliki puing-puing yang jauh lebih sedikit
dibandingkan Grup 4, tetapi puing-puing secara signifikan lebih banyak dibandingkan Grup 5
dan 7. Sementara itu, grup 7 (Median=0,5, IQR=1) memiliki tingkat puing-puing terendah, tetapi
tidak jauh lebih kecil dari Grup 5 (Median=1, IQR=1).

PEMBAHASAN

Struktur permukaan yang kompleks dari diamond-coated bur menahan sisa-sisa gigi dan
membuatnya lebih sulit untuk disterilkan dibandingkan dengan carbide bur. Meskipun demikian,
pada penelitian ini tidak ada perbedaan penghilangan (eliminasi) mikroorganisme berdasarkan
metode dekontaminasi bersamaan dengan sterilisasi karena tidak terlihat adanya pertumbuhan
mikroorganisme. Oleh karena itu, hipotesis nol pertama tidak ditolak. Sebuah penelitian yang
dilakukan oleh Sajjanshetty et al. mengungkapkan bahwa tidak ada satu pun teknik individu (i.e.,
manual scrubbing, hot air oven, glass bead sterilizer, ultrasonic cleaner, autoclave) yang benar-
benar efektif pada diamond-coated bur. Dari metode yang diuji, autoclave adalah yang paling
efektif dalam menurunkan unit pembentuk koloni Streptococcus mutans [10]. Sebaliknya,
penelitian ini menunjukan bahwa penggunaan pensteril uap (steam sterilizer) yang
dikombinasikan dengan berbagai prosedur pra-pembersihan (pre-cleaning) tidak menghasilkan
pertumbuhan salah satu dari empat bakteri yang diuji pada diamond-coated bur kasar. Selain itu,
penelitian ini mendukung pernyataan pabrikan bahwa diamond-coated bur steril dalam kemasan
masing-masing dan tidak memerlukan tindakan lebih lanjut sebelum penggunaan pertama.

Penelitian laburatorium sebelumnya mengungkapkan bahwa pembersih ultrasonik

berhasil mengurangi kotoran dari file endodontik [4,5]. Meskipun demikian, Gul et al.
mengungkapkan bahwa berbagai metode pra-pembersihan/pre-cleaning (yaitu, manual,
ultrasonik, manual dengan enzim, manual dengan ultrasonik) tidak efektif dalam menghilangkan
pewarna dari kepala diamond-bur [9]. Perbandingan dengan penelitian ini sulit dilakukan karena
penghilangan pewarna akan berbeda dengan penghilangan kotoran. Penelitian ini menunjukkan
perbedaan yang signifikan berdasarkan metode debridemen, sehingga hipotesis nol kedua
ditolak. Tidak ada metode pra-pembersihan yang benar-benar efektif untuk menghilangkan
semua kotoran dentin. Lebih lanjut, prosedur pembersihan manual (Grup 4) menghasilkan
penghilangan debris gigi yang jauh lebih sedikit dibandingkan dengan semua kelompok lain
dengan lebih dari 70% bur mempertahankan tingkat debris sedang hingga berat. Penggunaan
pembersih ultrasonik (Grup 6) menghasilkan pembersihan kotoran yang jauh lebih banyak
dibandingkan dengan prosedur pembersihan manual (Kelompok 4), tetapi pembersihan kotoran
secara signifikan lebih sedikit dibandingkan dengan penggunaan pembersihan manual dan batu
Clean-A-Diamond (Grup 5 ) atau pembersihan ultrasonik dan batu Clean-A-Diamond (Grup 7).
Penggunaan pembersih ultrasonik bersama dengan batu Clean-A-Diamond (Grup 7) dapat
menghasilkan sisa serpihan gigi paling sedikit dengan 96% bur menunjukkan sedikit atau tidak
ada sisa serpihan. Meskipun demikian, hal tersebut tidak berbeda secara signifikan dari
penggunaan pembersihan manual dan batu Clean-A-Diamond (Grup 5) dengan 94% bur
menunjukkan sedikit atau tidak ada puing yang tersisa. Penggunaan tambahan batu Clean-A-
Diamond tampaknya membuat peningkatan signifikan dalam dekontaminasi diamond-coated bur
dibandingkan dengan penggunaan prosedur pembersihan manual atau pembersih ultrasonik saja.
Lihat Gambar 2
 Pembuangan multi-use diamond-coated bur setelah sekali pakai mungkin tidak efektif
biaya. Menurut pabrikan, (perwakilan teknis, Brasseler), diamond-coated bur konvensional multi
guna yang dievaluasi dalam penelitian ini harus digunakan maksimal 12 kali sebelum dibuang,
tetapi hanya pada satu pasien. Satu pak berisi 5 bur kira-kira $60, dan setara dengan kira-kira $12
per bur jika tidak disterilkan dan digunakan kembali. Dengan diamond burs sekali pakai yang
baru, pabrikan merekomendasikan agar setiap bur dibuang hanya setelah satu kali persiapan.
Harga paket 25 bur kira-kira $50, yang setara dengan sekitar $2 per persiapan. Perbedaan biaya
akan bervariasi bergantung pada produsen dan jenis bur. Efisiensi pemotongan dan masa pakai
bergantung pada banyak faktor seperti kekasaran bur, bahan substrat (misalnya, enamel, dentin,
komposit, keramik), waktu preparasi, dan kecepatan serta torsi handpiece dan jumlah semprotan
air. Keterbatasan penelitian ini meliputi penggunaan hanya satu jenis dan kekasaran diamond-
coated bur dan hanya satu siklus debridemen dan sterilisasi.

Berdasarkan hasil penelitian ini, peningkatan biaya dan limbah yang dihasilkan melalui
penggunaan sekali pakai diamond-coated bur mungkin tidak dapat dibenarkan karena diamond-
coated bur yang terkontaminasi dan diinokulasi yang diteliti telah didebridemen dan disterilkan
dengan sangat baik setelah satu kali penggunaan. Jika menggunakan diamond-coated bur
beberapa kali, mungkin yang paling efektif bagi praktisi untuk mempertimbangkan
menggunakan protokol yang diuraikan di Grup 5 - debridemen dua detik dengan Clean-A-
Diamond stone diikuti dengan siklus pembersihan manual dan satu siklus sterilisasi uap, atau di
Grup 7 - debridemen dua detik dengan Clean-A-Diamond stone, pembersihan ultrasonik 15
menit, serta satu siklus sterilisasi uap. Salah satu dari kedua protokol ini harus memastikan
diamond-coated bur steril yang cukup bebas dari sisa-sisa gigi.

KESIMPULAN

Diamond-coated bur yang terkontaminasi dan diinokulasi yang diuji dalam penelitian ini berhasil
disterilkan untuk menghilangkan bakteri yang diuji. Sementara itu, penggunaan batu pembersih
(cleaning stone) dengan pembersihan manual atau dengan pembersih ultrasonik memberikan
jumlah sisa gigi yang tersisa paling sedikit pada kepala diamond-coated bur.

DISCLAIMER (KETIDAKTERLIBATAN)
Pandangan yang diungkapkan adalah milik penulis dan tidak mencerminkan pandangan resmi
mengenai kebijakan Uniformed Services University, Department of Defense, or atau
Komponennya. Penulis tidak memiliki kepentingan finansial di perusahaan yang materinya
dibahas dalam naskah ini