Sterilization and cross infection

control
 Exposure risks


Environment of dental operatory
 Air born contamination
 Direct contamination
 Indirect contamination
 HBV,HCV,HIV,CMV

Tuberculosis
 Measles, mumps,

Swine flu, SARS and many other infections
 Infection risks from HBV and HCV


Infection is by parenteral exposure; mucosal exposure
to infected blood or blood contaminated saliva; and by
spatter of blood contamination to eyes, mouth or
broken skin
 Paper cuts from blood contaminated request forms
seem to have transmitted HBV
 Plain saliva also can be weakly infectious
 Aerosolized, blood contaminated saliva and
respiratory secretions have not been shown to
transmit HBV

One in three parenteral exposures of nonvaccinated
personnel to HBV infected blood resulted in HBV
 HIV related to infection control


Found in very low levels in blood of infected persons
 Detected only in 28 of 50 samples of blood from
infected persons

In saliva HIV was detected in only 1 of 83 samples
 In dried blood 99% of HIV is dead by 90 min when
kept wet, the virus may survive for 2 or more days
 Killed by all methods of sterilization
 All disinfectants except some quarternary ammonium
compounds inactivate it in less than 2min
 Transmitted by heavily spattered blood-contaminated
fluids. Aerosol does not transmit HBV or HIV
Tansmission of HBV, HCV and hepatitis D
virus


Transmission is mainly by blood, intravenous drug
abuse and sexual contact
 Billions of HBV may occur per ml of infectious blood

HBV is also found in saliva at lower concentrations
 HBV can be transmitted by contamination of broken
skin, the mouth, or eyes with blood contaminated
saliva
 Serologic tests for HBV and HCV

 Tests are available for several antigens of HBV and for the
serum antibodies individual produce against them

HbsAg determines the presence of infection;whether they
are symptomatic or not

HbeAg determines individual’s ability to infect others
 Antibody against HB core antigen(anti-HBc) becomes
positive in all individuals a few months after infection and
remains positive for years. Its used as a marker for
previous infecton

Anti-HBs is performed to determine the presence of
antibodies that can protect against the future HBV infection

Anti-HCV test and PCR test for HCV RNA are available
 Exposure assessment protocol


Medical history
 Personal barrier protection gloves
 Hand washing
 Protective eyewear, masks, and hair protection
 Protective overgarments

Disposal of clinical waste
 Needle disposal
 Precautions to avoid injury exposure
 Rinse

Using cool water, rinse until no soap remains
 Types of equipment barriers

Plastic food
wrap

Paper

Headrest covers – paper, plastic

Also used – aluminum, various plastic covers
 Protective eyewear guidelines

All students, staff, and patients are to wear
protective eyewear during active treatment

Safety glasses with sideshields strongly advised

Once gloves are placed, not to be touched
 Mask guidelines

Worn when aerosol production is expected

Needs to be more
aerosol ‘cloud’ closely adapted as
when placing
 Overview of aseptic tichnique


During each appointment
 Remember whatever is touched is contaminated
 Directly touch what has to be touched
 Use one of the following to control contamination
 Clean and sterilize it
 Protect surfaces and equipments that are not sterilized
with disposable covers
 Use a paper towel, tongs, or plastic bag over gloves to
handle equipment briefly
 Scrub and disinfect noncriticle surfaces as well
 If need to adjust mask or handle
equipment briefly

Help from someone else or

Place overgloves, replace them with a new pair,
correct mask, dispose overgloves
 Disinfection principles


Disinfection cannot occur until fresh disinfectant is
reapplied to a thoroughly cleaned surface
 Disinfection does not stelize

Use according to manufacturer instructions
 Sterilization


Steam pressure sterilization (autoclave)
 Chemical vapour pressure sterilization(chemiclave)
 Dry heat sterilization (dryclave)
 Ethylene oxide (ETOX) sterilization
 Autoclaving


Sterilization with steam under pressure
 Time required at 250F (121C) is 15 min at 15 lb of
pressure

If the temp is increased to 273F(134C) to give 30 lb of
pressure, the time for wrapped instruments is reduced
to 7 min
 It is the most rapid and effective method for sterilizing
cloth, surgical packs and towel packs

Cannot autoclave heat sensitive instruments
 Burs can be protected by keeping them submerged in
2% sodium nitrite
 Chemiclaving


Similar to autoclaves
 Chemical vapor under pressure is used
 They operate at 270F (131C) and 20 lb of pressure
 Carbon steel and other corrosion sensitive burs,
instruments and pliers can be sterilized without rusting

Towel and heavy cloth wrappings of surgical
instruments may not be penetrated to provide
sterilization

Only dry instruments should be loaded
 Dry heat sterilization

 Dry heat sterilization is achieved at temp greater than

160C

Individual instruments must be heated at 160C for 30min
to achieve sterilization

Packs of instruments must be placed 1cm apart to allow
heated air to circulate

Approximately 60 to 90min may be required to sterilize a
medium load of lightly wrapped instruments

Short cycle high-temp dry heat ovens are available. They
operate at 188C to 191C, reducing sterilization time to
6min for unwrapped and 12 min for wrapped instruments
 Dry heat sterilization

 Advantages

Carbon steel instruments and burs do not rust, corrode,
or lose their cutting edges

Provide larger capacity at reasonable prices

Rapid cycles are possible at high temp

Disadvantages
 Cannot sterilize heat sensitive items like rubber or
plastic goods

Sterilization cycles are prolonged at low temp
 Ethylene Oxide Sterilization


ETOX sterilization is the best method to sterilize comlex
instruments and delicate materials

Automatic devices sterilize items in several hours and
operate at elevated temp well blow 100C
 Manufacturers should be consulted to obtain detailed
information about these sterilizers
 Boiling water


Does not kill spores and cannot steilize instruments
 Boiling is a method of high level disinfection
 Well cleaned items must be completely submerged
and allowed to boil at 98C to 100C for 10min
 Monitors of sterilization


Sterilization monitoring has four components
 Mechanical

Chemical indicator strips in each pack
 Weekly biologic spore test

Documentation notebook
 Liquid steriliants and high level
disinfection


Can kill bacterial spores in 6 to 10hrs
 Glutaraldehydes at 2% to 3% concentrations
 Organic matter and oxidation reduce activity of reused
disinfectant baths
 Placing wet instruments into disinfectant tray dilutes
the soln
 High level disinfection is used maily for plastic items
that enter the mouth and that cannot withstand heat
sterilization
 Dos and don’ts of instrument recycling

 Do the following

Wear protective puncture-resistant gloves to handle
used instruments

Keep instruments wet in an antibacterial soln before
cleaning
 Use an ultrasonic cleaning device

Test and maintain the ultrasonic device periodically

Use good quality sterilizer

Read the operator’s manual, and follow operation
instructions
 Have sterilizers annually inspected regarding gaskets,
timer, valves, and temp and pressure gauges
 Dos cont...

 Use proper water or chemical to operate, clean and

maintain sterilizer

Place only dry instruments in sterilizer

Use a wrap that will be penetrated by the steam or gas
used
 Load the sterilizer loosely; leave air space between large
packs
 Read sterilizer temp and pressure gauges daily

Use the complete sterilizer monitoring system
 Keep a record of daily indicators and spore tests
 don’t do the following

 Place instruments into any type of sterilizer unless so

instructed

Overwrap cloth packs or use impermeable wraps for
steam or chemical vapor pressure sterilization

Decrease the required time for sterilization
 Use closed, nonperforated trays, foil, canisters, or other
sealed containers in gas or steam sterilizers
 Overload or cram packs together in the sterilizers

Add instruments to a sterilizer without restarting the cycle
 Sterilize viability control strips supplied with spore tests
 Control of contamination from spatter
and aerosol


Rotary equipments spatter oral fluids and
microorganisms into the air
 Aerosolization of mycobacteria can cause pulmonary
tuberculosis
 There is no way to eliminate air-born contamination
completely
 Can be reduced with using rubber dam and high
volume evacuation
 Personal barriers must be used