ASEPSIS IN ENDODONTICS

Definitions:
• Sterilization: Process by which an articles, surface or medium is freed
of all microorganism either in vegetative or spore form.

• Disinfection : Process which reduces the number of viable

microorganism to an acceptable level but may not inactivate some virus
and bacterial spores.

• Antiseptic : Chemical which can be safely applied to skin or mucus

membrane surfaces and used for preventing infection by inhibiting
growth of bacteria.

• Cross infection control :Is the sum total of all the measures taken to
prevent subsequent infection.
Why is Infection Control Important in Dentistry?
• Both patients and dental health care personnel (DHCP) can be exposed to
pathogens

• Contact with blood, oral and respiratory secretions, and

contaminated equipment occurs

• Proper procedures can prevent transmission of infections among

patients

Modes of Transmission
• Direct contact with blood or body fluids
• Indirect contact with a contaminated instrument or surface
• Contact of mucosa of the eyes, nose, or mouth with droplets or
• spatter Inhalation of airborne microorganisms
DCNA 2003;691-708
Chain of infection
• All links must be connected for infection to take
place
Pathogen

Susceptible Host Source

Entry Mode
Exposure risks in dentaloperatory

A) Airborne contamination
B) Hand-to-surface contamination
C) Cross infection
D) Patient vulnerability
E) Personnel vulnerability

A) Airborne contamination
• A high speed handpiece is capable of creating airborne
contaminants.

• It exist in the form of aerosols, mists, and spatter

Aerosols are invisible particles ranging from 5- 50
• Remain suspended in air for hours
microns.
• Can carry any respiratory pathogens to the lungs.
Mists are droplets approaching 50microns or
more
• Tend to settle gradually from air after 5-15 min
• Both aerosols and mists produced by cough of patient with
unrecognized active pulmonary or Pharyngeal tuberculosis are likely to
transmit the infection.

Spatter are particles larger than 50 microns and are visible.

• They have a distinct trajectory, usually falling within 3 feet of patient

mouth.

• Spatter has a potential of causing infection of dental personnel by

blood
borne pathogens.
B) Hand-to-surface-contamination

• With saliva contaminated hands, the dentist could repeatedly contact or

handle unprotected Operatory surfaces during treatment if not careful.

• Amalgamator, light curing devices, camera equipments are also subject to

heavy contamination by soiled hands.

• Mobile phones may also act as an important source of nosocomial

pathogens in the dental setting

• Contamination free maintenance of these items is a priority

objective today.
C) Cross infection

• “The transmission of infectious agents between patients and staff within a

clinical environment”

• Transmission may result from person to person contact or via

contaminated objects.

• Patient-to-patient transmission of hepatitis B virus (HBV) -

transmission of a blood borne pathogen in a dental setting in the United
States.
• The major route of cross infection in Conservative Dentistry and
Endodontics is via infection through intact skin or mucosa due to
accidents involving sharps, or direct inoculation onto cuts and abrasions
in the skin.
D) Patient vulnerability
• Although infection risks for dental patients have not been as well
investigated as those of hospital patients, they appear to be low.

• Nine cluster cases of dentist-to-patient transmission of HB and one cluster

case of HIV has been well documented since 1971.

• In 1999, a group of six patients was found to be with same strain of HIV
virus that infected the Florida dentist who treated them.

E) Personnel vulnerability

• When dental personnel experience exposure of saliva, blood, and possible

injury from sharp instrumentation while treating patients, they are more
vulnerable to infections if they have not had proper immunizations or
used the protective barriers.
Infection control program
• To reflect new data, materials, technology, and equipment.
When implemented.

• Types of infection control program

• 1. IC program by center for disease control and
prevention
• 2. IC program by ADA (American Dental Association)
• 3. IC program by Federal Occupational Safety and Health
Agency (OSHA)
Standard Precautions

• Wash hands before and after every patient.

• Wear gloves when touching blood, body fluids, secretions, and
contaminated items.
• Use care when handling sharps.
• Wear a mask and eye protection, or a face shield.
• Carefully handle contaminated patient care items to prevent the transfer
of
microorganisms to people or equipment.
• Use a mouthpiece or another ventilation device as an alternative to
mouth- to-mouth resuscitation when practical.
• Standard Precautions must be used in the treatment of all patients.
Hand Hygiene

• Wash hands before putting on gloves and

immediately after removal

• At beginning of treatment period - jewelry,

and rings should be removed

• long fingernails can harbour

pathogens, nails should be kept short.

• Treatment room sinks be equipped with

“hands-free” faucets that are activated
electronically or with foot pedals
• use liquid soap as bar soap may transmit contamination
• Waterless antiseptic agents are alcohol based products that are available in gels,
foams, or rinses.

• Hand cleansers containing a mild antiseptic like 3% PCMX

(parachlorometa- xylenole) or chlorhexidine - preferred to control transient
pathogens and to suppress overgrowth of skin bacteria
• 4% chlorhexidine – broader activity but hazardous to eyes
Personal Protective Equipment
• Protective clothing
• Protective eyewear
• Surgical mask
• Gloves
Protective Clothing Requirements
• should be made of fluid-resistant material.
• To minimize the amount of uncovered skin, clothing should have long
sleeves and a high neckline.
• Buttons, trim, zippers, and other ornamentation (may harbour
pathogens) should be kept to a minimum.
Guidelines for the Use of Protective Clothing
• not worn out of the office for any reason
• Protective clothing should be changed at least daily and more often
if visibly soiled.
• If a protective garment becomes visibly soiled or saturated with chemicals
or body fluids, it should be changed immediately.

• Hot water (70 -158 F) or Cool water containing 50 to 150 ppm of

chlorine can be used- to provide more antimicrobial action
Protective Masks
• Worn over the nose and mouth to protect from inhaling
infectious organisms
• A mask with at least 95 percent filtration efficiency for particles 3 to 5
micrometers (μm) in diameter should be worn whenever splash or spatter
is likely
• Recommendations for changing mask – after 20 min in aerosol & 60 min
in non-aerosol environment
• When not in use, it should never be worn below the nose or on the chin.
• Two most common types of masks are the domeshaped and flat types
• Average surgical mask does not protect one from the influx of very small
virus particles in the air

• National Institute for Occupational Safety and Health (NIOSH) and the
Centers for Disease Control and Prevention (CDC) recommend the use of
a NIOSH-certified N95 for the protection of healthcare workers who
come in direct contact with patients with H1N1
Protective Eyewear

• Worn to protect the eyes against damage

from aerosolized pathogens

• Eyewear must be optically clear, anti-

fog, distortion-free, close-fitting and
should be shielded at the sides

• BBP Standard requires the use of

eyewear with both front and side
protection during exposure prone
procedures
Gloves

• Medical grade nonsterile examination gloves and sterile surgical gloves are
medical devices that are regulated by the U.S. Food and Drug
Administration (FDA).
• Different types of gloves are used in a dental office

Examination Non–Latex-
Gloves/ surgical Overgloves Utility Gloves Containing Gloves
gloves
Guidelines for the Use of Gloves

• Single use.
• May not be washed, disinfected, or sterilized.
• Gloves DO NOT replace the need for hand hygiene.
• Wash hands before donning gloves and upon glove removal
• Open new fresh gloves just before starting procedure
• Replace torn or damaged gloves immediately.
• Do not wear jewellery under gloves
• Remove contaminated gloves before leaving the chair side during
patient
care, and replace them with new gloves before returning to patient care
Maintaining Infection control while gloved

• Anticipate required materials and have those items ready and

easily accessible for each procedure to save time and minimize
cross- contamination
• When opening a container use overgloves, a paper towel, or a sterile
gauze sponge . In doing this, take care not to touch any surface of the
container.
• Use sterile cotton pliers to remove an item from the container
Managing Contaminated Sharps

• Contaminated needles and other disposable sharps must be placed into

a
sharps container.
• The sharps container must be puncture-resistant, closable, leakproof,
and color-coded
• Sharps containers must be located as close as possible

• Always use the single-handed scoop technique or some type of

safety device
Materials impervious to moisture that are used to prevent contamination
of
surfaces.
▫ Plastic sheets
▫ Impervious paper
▫ Aluminum foils
Used in areas difficult to clean and disinfect
- Air water syringe
- Dental light handles
- Electrical toggle switches
- Head rest
- X Ray unit heads
Waterlines and water quality
• Microbes exist in the dental unit water line
as biofilm.

• bacteria may include atypical mycobacteria,

pseudomonas, and Legionella

• CDC has recommended that dental unit

treatment water contain less than 500
colony- forming units (cfu) per milliliter of
bacteria.

• Disinfectants such as an iodophore or diluted

sodium hypochlorite that are used to clean
the system
 • All waterlines must be fitted with non-return (anti-retraction) valves to
help
prevent retrograde contamination of the lines by fluids from the oral
cavity.

• Air and waterlines from any device connected to the dental water system
that enters the patient’s mouth (e.g. handpieces, ultrasonic scalers, and
air/water syringes) should be flushed for a minimum of two minutes at
the start of the day and for 30 seconds between patients
Protocol to be followed
for high risk patients:-
• High risk patients should be seen last
• Protective attire and barrier techniques
• Vaccines for dental health-care workers
• Use and care of sharp instruments and needles
• Cleaning and disinfection of dental unit and environmental surfaces
• Use single-use disposable items and equipment
• Consider items difficult to clean (e.g., endodontic files, broaches) as single-
use
disposable
• Keep instruments moist until cleaned
• Clean and autoclave at 134°C for 18 minutes
Immunisation
• Dental personnel should maintain up-to-date immunization records
that
include vaccination against:
▫ A) HEPATITIS B
▫ B) RUBELLA
▫ C) MEASLES MMR
▫ D) MUMPS
▫ E) INFLUENZA
▫ F) POLIO
▫ G) TETANUS/DIPHTHERIA
 Recommended Vaccines for Oral Health Care workers

Hepatitis B Two doses IM 4 weeks apart, third dose 5

months after second
(Recombinant )

MMR One dose SC ..No booster

(Live Virus Vaccine)

Influenza Vaccine Annual Vaccination

(inactivated whole virus and split –
virus vaccine)

Tetanus –Diphtheria Two doses IM 4 weeks apart, third dose 6

– 12 months after second.
(Toxoid)
Booster dose every 10 years
Varicella One dose SC for persons ages 12 months
(Live virus vaccine) to 12 years, Second dose 4 – 8 weeks
after first for those ages 13 and up
Instrument processing

• Contaminated instruments can transmit infections between

patients, correct reprocessing of instruments between each patient
use is essential

Steps Involved

• Presoaking
• Cleaning
• Packaging
• Sterilization
• Drying or cooling
Presoaking
• Most disinfectants do not act in the presence of debris, so they should be
removed. It is easier to remove the debris before it dries.

• Placing the instrument in a presoak solution until time is available for

full cleaning prevents drying and begins to dissolve or soften the debris.

• Presoak solutions used are detergents, enzymes, phenols, quaternary

ammonium compounds.
Cleaning
• All items to be sterilized must be properly cleaned first to reduces
bio- burden

Ultrasonic cleaners
• These are safest and most efficient ways to clean instruments

• Ultrasonic cleaning is 9 times more effective than hand cleaning

• An ultrasonic cleaning device provides fast and thorough cleaning
without damage to instruments
• Ultra sonic cleaners- acidic, alkaline, neutral, de ionized, enzymatic.
• eg:CO Z 3L, BRANSON B200
Packing

• Cloth packs, wraps, or plastic bags are suitable for instrument

containment if they are compatible with the method and temperature
of sterilization.

• Various kinds of instrument trays and cassettes are manufactured to

contain the instruments at chairside, and they can be placed in an
ultrasonic cleaner, rinsed, and packaged ready for sterilization.
STERILIZATIO
N
• Most instruments contact mucosa or penetrate oral tissues, it
is essential that reused instruments be thoroughly cleaned and
sterilized by accepted method that can be routinely tested and
monitored.

4 accepted method of sterilization -

1. Steam pressure sterilization (Autoclave)
2. Chemical vapor pressure sterilization (Chemiclave)
3. Dry heat sterilization (Dryclave)
4. Ethylene oxide sterilization(ETOX)
Autoclave
• Sterilization with steam under pressure is performed in a steam autoclave
• Time required at 1210 C is 15 mins at 15 lbs of pressure or 134o C at 30 lbs pressure
for 7 min

Advantages
• most rapid and effective for sterilizing cloth surgical packs and towel packs

Disadvantages of Autoclave
• Items sensitive to heat cannot be sterilized
• It tends to corrode carbon steel burs and instruments
Sterilization Of Burs In
Autoclaves
• Burs can be protected by keeping them submerged in a small amount of 2%
sodium nitrite solution.

• Prepare fresh sodium nitrite solution by adding 20gms of crystal to 1 liter of

water and place it in a perforated beaker containing burs.

• The solution should be above the burs by approximately 1cm

Chemiclave

• Chemiclaves utilize chemical vapor for sterilization produced using

formaldehyde- and-alcohol formulation that is water-free
• operates at 131 C and 20 lbs of pressure for 30 min

Advantages
• Carbon steel and other carbon sensitive burs, instruments and pliers are sterilized
without corrosion

Disadvantages
• Items sensitive to elevated temperature will be damaged
• Towel and heavy clothing cannot be sterilized.
Dry Heat Sterilization
Conventional dry heat ovens:
• Most common time temperature cycles are 170°C (340°F) for 60 minutes,
160°C (320°F) for 120 minutes, and 150°C (300°F) for 150 minutes.
• Recently, more rapid dry heat sterilizers (COX sterilizers) have become available;
these can be operated at 370°F for 6-, 8- or 12-minute cycles
Advantages
• Carbon steel instruments and burs do not rust, corrode, or lose their temper or
cutting edges if they are well dried before processing.
Disadvantages
• High temperatures may damage more heat-sensitive items such as rubber or
plastic goods.
• Sterilization cycles are prolonged at lower temperatures.
Ethylene oxide sterilization

• Best method of sterilization of complex instruments and delicate materials.

• Automatic devices sterilize items in several hours and operate at elevated
temperature well below 1000 C
• Less expensive device operates at room temperature to sterilize overnight

Advantages
• Units with large chambers hold more instruments or packs per cycle

Disadvantages
• Porous or plastic materials absorb the gas and require aeration for 24 hours or
more before it is safe for them to contact skin or tissues.
Boiling Water

• Boiling water does not kill spores and cannot sterilize instruments
• Incase of sterilizer breakdown - this method should be followed
• Well cleaned items must be completely submerged and allowed to boil at 1000 C for
10 mins

Disinfection, sterilization, and preservation, ed

4, Philadelphia, 1991, Lea & Febiger
Endodontic instruments sterilization

• Proper steam autoclaving reliably produced completely sterile

instruments.

• Salt sterilization and glutaraldehyde solutions may not be

adequate sterilization methods for endodontic hand files and
should not be relied on to provide completely sterile instruments
• Files sterilized by autoclave and lasers were completely sterile.
Those sterilized by glass bead were 70% sterile and those
with glutaraldehyde were 80% sterile.
Individual instruments can be sterilized in the following ways -

• Glass slab by swabbing with tincture of thimerosal, followed by

a double swabbing with alcohol.

• Gutta-percha cones may be kept in sterile screw capped vials

containing alcohol.

• To sterilize gutta-percha cone freshly removed from the box-

immerse in 5.2% sodium hypochlorite for 1 min, then rinse
with hydrogen peroxide and dry between 2 layers of sterile
gauze.
• Rubber dam is sterilized by ethylene oxide.

• Carbon steel instruments and burs are best sterilized by dry heat or
chemiclave.

• Sterilization dental cements, calcium sulphate is done by gamma radiation

 DISINFECTION

Methods of disinfection
• Disinfection by cleaning
• Disinfection by heat
• Low temperature steam
• Disinfection by chemical agents
LEVELS OF DISINFECTANTS

• Alcohols (Low level disinfectant)

Ethanol and isopropyl alcohols are used as antiseptics
Possess some antibacterial property
act by denaturing protein
to have maximum effectiveness alcohol must have 10 min
contact
• Phenolic compounds (Intermediate level)
These were introduced to reduce their side effects but are
still toxic to living tissues.
They act by precipitating the proteins and destroy the cell
wall.
• Aldehyde compounds
Formaldehyde
Broad spectrum anti microbial agent
Flammable and irritant to eye, skin and respiratory tract.
Has limited sporicidal activity
Not preferred due to its pungent effect.
• Glutaraldehyde
Toxic, irritant and allergic
A high level disinfectant
Frequently used for heat sensitive material.
A solution of 2% glutaraldehyde requires immersion of 20
min for disinfection and 6-10 hrs of immersion.
 ANTISEPTICS
• ALCOHOLS
Two types of alcohol are used ethyl alcohol and isopropyl
alcohol.
Used for skin antiseptics
Their benefits is derived primarily in their cleansing action,
Ethyl alcohol is used in conc of 70%.
Ispropyl-60% to 70%
• AQUEOUS QUATERNARY AMMONIUM COMPOUNDS
Benzalkonium chloride is the most commonly used one.
Well tolerated by tissues.
• IDOPHOR COMPOUNDS
Used for surgical scrub,soaps and surface antiseptics.
Usually effective within 5- 10 mins.
Discolour surfaces and clothes.
• Chlorine compounds
Sodium hypochlorite and chlorine dioxide are most
commonly used.
A solution of one part with nine parts of water is used.
chlorous acid and chlorine dioxide provides disinfection in 3
min.
Hospital waste categories and
disposal

Park 20th/698
 Conclusion
• Infection control measures in dentistry are most vital for
mutual health safety of patient and health care
professionals.
• There are several key players and elements to achieve the
highest standard of infection control. These include the Dental
health care professionals and the patients.
• Rigid implementation of evidences based infection control
measures should be strictly followed in dental practice.

“Whatever is touched is contaminated”

Thank you.