STERILISATION OF PROSTHODONTIC

INSTRUMENTS AND DEVICES

1
Contents-
 INTRODUCTION
 TERMINOLOGIES
 CLASSIFICATION
 DETAILS OF INDIVIDUAL AGENTS
 BIOLOGICAL CONTROLS
 STERILIZATION IN DENTISTRY
 REFERENCES

2
Introduction
 Microorganisms are ubiquitous.

 Since pathogenic cause contamination,

infection and decay, it becomes necessary to remove
microorganisms
or
destroy them from materials and areas.

 This is the objective of sterilization.

3
 STERILIZATION Sterilization (or sterilisation) is a term referring to any
process that eliminates or kills all forms of life and other biological
agents including transmissible agents (such as fungi, bacteria, viruses, prions,
spore forms, unicellular eukaryotic organisms such as Plasmodium, etc.) present
in a specified region, such as a surface, a volume of fluid, medication, or in a
compound such as biological culture media.

( WHO Glossary )

 STERILE: Free from all living microorganisms; usually described as a

probability (e.g., the probability of a surviving microorganism being 1 in
1 million).(CDC guidelines 2008)

4
 DISINFECTION: Destruction of pathogenic and other kinds of
microorganisms by physical or chemical means. Disinfection is less lethal
than sterilization, because it destroys the majority of recognized
pathogenic microorganisms, but not necessarily all microbial forms (e.g.,
bacterial spores).(CDC guidelines 2008)

 Disinfection is a process of removing or killing most, but not all,

viable organisms.

5
 ANTISEPSIS is the prevention of infection, usually by
inhibiting the growth of bacteria in wounds or tissues

 BACTERICIDAL AGENTS: Those which are able to kill

bacteria.

 BACTERIOSTATIC AGENTS: Only prevents the

multiplication of bacteria which may however remain alive.

 DECONTAMINATION: The process of rendering an article

or area free of danger from contaminants, including microbial,
chemical, radioactive and other hazards.

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METHODS OF STERILIZATION AND DISINFECTION

PHYSICAL METHODS CHEMICAL METHODS

• SUNLIGHT • ALCOHOLS
• DRYING • ALDEHYDES
• DRY HEAT • DYES
• MOIST HEAT • HALOGENS
• FILTRATION • PHENOLS
• RADIATION • SURFACE-ACTIVE
• ULTRASONIC AND SONIC AGENTS
VIBRATIONS • METALLIC SALTS
• GASES

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PHYSICAL
AGENTS
 Sunlight:- Active germicidal effect due to the combined effect of U.V and
heat rays. e.g.:- river, tanks & lakes.

 Drying:- 4/5ths of weight of bacterial cell consist of water and hence drying has
a deleterious effect on many bacteria.
 Heat :- most reliable and commonly applied way of sterilization
Dry heat
 Flaming:- Inoculating loops or wires, the tip of
forceps & needles and spatulas are held in a
bunsen flame till they become red hot in order to
be sterilized.

 Incineration :- Rapidly destroying materials such as

soiled dressings, bedding, animal carcasses,
pathological materials etc.

8
DRY HEAT

Principle-

- Protein denaturation.

-Oxidative damage.

-Toxic effects of elevated levels of

electrolytes.

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HOT AIR OVEN:-

 It’s the most widely used mode of sterilization

 Temp.- 160°C ( 320° F ) for 2 hr.

 Uses :-
-Glasswares like glass syringes, petridishes, flasks,
pipettes & test tubes.

-Surgical instruments like scalpels, scissors,

forceps
etc..
- Chemicals such as liquid paraffin, fats,
greases, Sulphonamide, dusting powder etc. 13
  Precautions:-
1) Not to be overloaded.
2) Must be fitted with fans for even distribution
of hot air.
3) Materials to be sterilized should be perfectly
dry.
4) Rubber materials (except silicone rubber)
will not withstand the temperature.
5) Allowed to cool for 2 hrs before opening the
doors. Advantage: Disadvantage :
Economical. Hot air is bad
conductor of heat
Does not rust metals hence it has less
penetrating power
Easily monitored .

Used for
anhydrous oils & 14
 MOIST HEAT

• pasteurisation of milk.
TEMPERATUR • Inspissation.
E BELOW 100O • Vaccine bath.
C • Low temperature steam formaldehyde.

• Boiling
TEMPERATUR • Tyndallisation
E AT 100O C • Steam sterilizer at 1000 C

TEMPERATUR • Autoclave
E ABOVE
100O
15
 AUTOCLAVING
Boiling water alone is INSUFFICIENT to kill spores and viruses

water boils when its vapour pressure equals to that of surrounding atmosphere

Hence, when pressure increases inside closed vessel

Temperature at which water boils increases

saturated steam has penetrative power

When steam comes in contact with a cooler surface it condenses to water

and gives up latent heat to that surface. The large reduction in volume of steam
sucks in more steam to the site and the process continues till the temperature
of article is raised to that of steam.
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 AUTOCLAV
E
 Three major factors for effective autoclave:
1. Pressure: 15psi.
2. Temperature: 121oC
3. Time: 15 mins.
 Higher temperature and pressure require shorter
time
for sterilisation.
Pressure (psi) Temperature Time (mins)
(°C)
• 15 • 121 • 15
• 20 • 126 • 10
• 20 • 134 •3

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 Types of autoclave
DOWNWARD DISPLACEMENT
 Also known as Gravity displacement unit.
 This is because of the method of air removal in the sterilization
chamber.

POSITIVE PRESSURE DISPLACEMENT

 It’s an improvement over downward displacement autoclave.
 Steam is created in a second, separate chamber and held until the
proper amount to displace all of the air in the sterilization
chamber is accumulated.
 The steam is then released into the sterilization chamber in a
pressurized blast, forcing the air out through the drain18 hole and
starting the sterilization process
NEGATIVE PRESSURE DISPLACEMENT

 one of the most accurate types of unit available

 Once the sterilization chamber door is closed, a vacuum pump

removes the air.

 Steam is created in a second, separate chamber.

 Once the air has been completely removed from the sterilization
chamber, the steam is then released into the sterilization chamber in a
pressurized blast much like that of a positive pressure displacement
unit.

 The negative pressure displacement unit is able to achieve a high

"Sterility Assurance Level" (SAL), but the system can be quite large
and costly. 16
TRIPLE VACUUM AUTOCLAVE

 A triple vacuum autoclave is set up/function in a

similar fashion to a negative pressure displacement.

 This is repeated three times, hence the name "triple

vacuum" autoclave. This type of autoclave is suitable
for all types of instruments and is very versatile

17
Considerations during autoclaving
1. Ensure complete air removal for temperature
to reach 121°C.

2. Ensure loose packing in the chamber.

3. Tightly sealed materials may become

dangerously pressurized causing injury when
removed.

USES:
Disposable syringes, Non disposable syringes,
Glassware, Metal instruments, surgical dressing,
Surgical instruments, Laboratory equipment, Culture
media, Pharmaceutical products. 22
 Advantage:- Disadvantage:-

Economical. Moisture retention

Good penetration.
Causes corrosion

Short cycle Carbon steel gets

damaged

time. Easily Dulling of unprotected

cutting edges.
Nomonitored
special chemicals
or exhaust required. Destruction of heat
sensitive
materials. 23
Filtration helps to remove bacteria from heat labile such as sera and solutions of
sugars or antibiotics used for preparation of culture
media.
Candle Filter Asbestos Filter

Sintered Glass Filters Membrane Filters

2
4
 RADIATIO
N
1) Non-ionising radiation:
 Uses longer wavelength and lower energy. And hence lose
the ability to penetrate substances, and can only be used
for sterilizing surfaces
 Eg. infrared radiation is used for rapid mass sterilization
of prepacked items eg. Syringes, catheters.
 UV radiation is used for disinfecting enclosed
areas like operation theaters, laboratories.

2) Ionising radiation:
 Uses short wavelength, high-intensity radiation with
high penetrative power to destroy microorganisms.
 This radiation can come in the form of gamma
or X-rays that react with DNA resulting in a damaged
cell.
 Since there is no appreciable increase in the temperature,
it is also known as COLD STERILIZATION. 25

 Used for sterilizing plastics, swabs, metal foils etc.

ULTRASONIC and SONIC CLEANING

 More effective than manual cleaning.

 Removes dried serum, whole blood, plaque, zinc
phosphate and polycarboxylate cements from instruments,
metal surfaces and dentures.
 Minimizes handling of contaminated instruments.
 During cleaning, totally submerge instruments in
the ultrasonic solution for 2 to 20 minutes .
 Ultrasonic solution should be changed atleast once
a day.

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BIOLOGICAL CONTROLS FOR DIFFERENT
STERILIZATION METHODS

METHOD OF BIOLOGICAL CONTROL

STERILIZATIO
N

Hot Air Oven Bacillus subtilis

Clostridium tetani

Autoclave Geobacillus stearothermophilus

Filtration Serratia marcescens,

Pseudomonas diminuta

Ionizing Radiation Bacillus pumilis 29

 CHEMICAL AGENTS

LIQUIDS GASES
• Alcohols • Formaldehyde
• Aldehydes • Ethylene Oxide
• Phenols • Plasma
• Halogens
• Heavy Metals
• Surface Active
Agents
• Dyes

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 Protein coagulation

 Disruption of the cell membrane

 Removal of the free sulphydryl

groups

 Substrate competition

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 SPAULDING’S CLASSIFICATION
Critical
instruments
Penetrate the soft tissue  Contact the mucous
 Contact the bone
Enter into or contact the
blood stream
They should be
thoroughly cleaned and
heat sterilized if they
are to be reused,if heat
sensitive ethylene oxide
or hydrogen peroxide
gas plasma is used.
Eg: Surgical instruments, Scalers,
Scissors
Scalpel blades
Forceps
Bone grafts
Semi-critical Non-critical
Instruments
Instruments
 Come into contact with intact
membrane or non skin. Cleaned or treated with
intact skin but will not low-level disinfectants.
penetrate the soft
tissue. Glutaraldehyde Eg : X-Ray tubes, Light
is most commonly handles, Counter tops
used high-level
disinfectant.
Eg : Mouth mirror,
impression trays,
handpieces, probe,
tweezers
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33
 ALCOHOL

Mechanism of Action : Denaturation of Proteins

 Isopropyl alcohol
Used as a skin
 70% ethyl disinfectant
alcohol

 Methyl alcohol is active against the

fungal spores and used to treat cabinets
and incubator
 Suitable for skin preparation before
venepuncture

Disadvantage : . Inflammable
. Mucous membrane irritant.
. Promotes rusting.
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 ALDEHYDES

A)Formaldehyde (formalin)
In aqueous solution it acts as a bactericidal and sporicidal
Active against Gram -ve bacteria, spores, viruses (HB, HIV) & fungi

Aqueous soultion: Formalin(37% solution) - 10% formalin +

0.5% Na tetraborate used to sterilize clean metal instrument e.g.
Endoscope, dialysis equipment.

Gaseous form: Fumigation of wards/corridors/ICU’s

DISADVANTAGE: Have pungent odour & irritating effect on

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skin & mucous membrane.

B.GLUTARALDEHYDE / CIDEX ( 2% alkaline NaHCO3)

 High level disinfectant

 Especially active against tubercle

bacilli,fungi, and viruses

 Less toxic than formaldehyde

 Can be safely used to treat corrugated rubber

anaesthetic tubes, face masks, metal instruments.

 Exposure time: > 10hrs.

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PHENOLS:
Acts by cell membrane damage thus
releasing cell contents and causing lysis

 Eg. C r e s o l ( LYSOL) ,chlorhexidine (

SAVLON),chloroxylenol (DETTOL)

 Phenol is commonly found in mouthwashes, scrub soaps

and
surface disinfectants

 Low efficiency disinfectant

 Used for decontamination of the hospital environment, including

laboratory surfaces.
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HALOGENS :

A) Chlorine compounds:

 Bleaching powder or hypochlorite

solution mostly used disinfectant for HIV
infected material.

 in concentration of 0.05 or 0.5% used for

surface material and instruments disinfection

 Should be prepared daily because of

instability of sodium hypochlorite
solution

 viruses
Active (HB, bacteria,
against HIV) spores, fungi and 38
B) IODOPHORS & IODINE
 Active against bacteria, spores & some
viruses & fungi

 Suitable for skin preparation, mouthwash &

as a surgical scrub
(7.5% Povidone+iodine= Betadine)

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 DYES
Two group of dyes
1.Aniline
2.Acridine

• More active against Gram+ve than Gram –ve.

• Both are bacteriostatic in high dilution but have low bacteriocidal activity.

1. ANILINE DYE- includes

a) Brilliant green
b) Malachite green
c) Crystal violet
 Lethal effects on bacteria is due to reaction with acid group in the cell.

2. ACRIDINE DYES
a) Proflavine
b) Acriflavine
c) Euflavine

 Impair the DNA complex and prevent replication.

 SALT
S
 Salts of heavy metals have toxic effect on bacteria.

 The salts of copper , silver and mercury are used as disinfectant.

SURFACE ACTIVE AGENTS

 substances which alter energy relationships at

interfaces,producing a reduction of surface tension, are known as
surface active agents. E.g. CETAVLON OR CETRIMIDE

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 ETHYLENE OXIDE
•Highly inflammable and in concentration more than 3% highly
explosive and hence not used for fumigation of rooms

•Mix with carbon dioxide or nitrogen to eliminate its explosive

tendency

• Effective against all types of micro-organism including

viruses and spores.

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 RECOMMENDED CONCENTRATIONS

DISINFECTANT CONCENTRAT
I ON

Ethyl Alcohol 70%

Gluteraldehyde 2%
Lysol 2.5%
Savlon 2%
Dettol 4%
Bleaching powder (Calcium hypochlorite) 14 gm in 1 L water

Sodium hypocholorite 1%, 0.1%

Betadine (Iodophore) 2%
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STERILISATION AND
DISINFECTION IN
DENTAL CLINIC

38
The four accepted methods of sterilization in dental offices
are:

 Steam pressure sterilization (autoclave)

 Chemical vapor pressure sterilization(chemiclave)

 Dry heat sterilization(dryclave)

 Ethylene oxide(ETOX) sterilization

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Steam pressure sterilization(autoclave)
 It is performed in a steam autoclave. For light load of
instruments the time required at 121o C is 15 minutes at 15psi of
pressure. It works on principle as that of pressure cooker.

Advantages: rapid and effective.

Disadvantages: items sensitive

Tends to rust carbon steel

instruments and burs.

Sterilization of burs in
autoclaves.

burs can be protected by

keeping them submerged in 40

small amounts
Chemical vapour pressure sterilization

 Performed in a chemiclave.

Operate at 131oC and 20lbs of pressure. they are similar to

steam sterilizer and have cycle of 30minutes.

• carbon steel and other corrosion sensitive instruments and pliers

are sterilized without rust or corrosion.

46
 Advantages Disadvantages

1. Carbon steel and other 1. Items sensitive to the

corrosion-sensitive elevated temperature will

instruments are said to be be damaged. Vapor odor is

sterilized without rust. offensive, requires aeration.

2. Relatively quick 2. Heavy cloth wrappings of

turnaround surgical instruments may not
time for instruments. be penetrated to provide

3. Load comes out dry. sterilization.

4. Sterilization is verifiable.

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Dry heat sterilization

 Conventional dry heat ovens

 Short cycle, high temperature dry heat oven.

They have heated chambers that allow air to circulate by gravity flow.

A rapid high temperature processing that uses forced draft oven(air circulates with
a

fan or blower)

Operate at approximately 188oC-191oC

43
Advantages Disadvantages
1.Reasonable price 1.rubber and plastic materials

2.carbon steel instruments and might damage.

burs do not rust or corrode or lose 2.heavy load of instruments

temper or cutting edges. defeats sterilization.

3.Rapid cycles possible at high 3.Improper calibration may

temperatures damage instruments

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Ethylene oxide sterilization
Etox sterilization is the best method for sterilizing
complex instruments and delicate materials.
Advantages
 Operates effectively at low temperatures
 Gas is extremely penetrative
 Can be used for sensitive equipment like handpieces.
 Sterilization is verifiable
Disadvantages
 Potentially mutagenic and carcinogenic.
 Requires aeration chamber ,cycle time lasts hours
 Usually only hospital based.

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 OPERATORY ASEPSIS
 In the dental operatory, operatory surfaces that are
repeatedly touched or soiled are best protected with
disposable covers(barriers)that can be discarded after
each treatment.

 For dental unit trays, paper, plastic film or surgical pack

wraps (paper or towels) should cover the entire tray.

 Clear plastic 15-gallon waste container bags fit many

chair backs , control units , and x-ray equipment.

46
 Gigasept which contains succindialdehyde and
dimethoxytetrahydrofuran are used for disinfection of
plastic and rubber materials eg: dental chair

47
Asepsis of surgery theaters
 Fumigation is done by two methods:

1. Electric boiler method- 500 ml of formaldehyde

(40%) added to distilled water in electric boiler.
When the water heats fumes are generated.

2. Potassium permanganate – heat is induced by

oxidizing action of 150gm potassium
permanganate to 280ml of formalin is added
which reacts and generates fumes.

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DENTAL RADIOGRAPHY
CDC(MMWR),dec19,2003vol.52

• Contamination of working area occurs from saliva.

• X-ray tube head, exposure selector and timer button are likely to get
contaminated by saliva.

• Precaution to be taken up :

1. Put on gloves.

2. Place the film packets and film holders in special tray.

3. Contaminated films(exposed films) to be placed in separate tray.

49
4. Film holding device to be rinsed in running water to remove saliva.

5. Metallic part to be autoclaved.

6. Plastic attachments to be kept in chlorhexidine solution.

7. Wipe the x-ray tube head, exposure selector, timer button and film
packets with detergents.

8. Tube can be wrapped in disposable plastics.

9. Film packets to be discarded in yellow bags.

50
• BIO-FILMS :

CDC(MMWR),dec19,2003vol.52

• Tubes connecting hand-pieces, air/water syringe &

ultrasonic scaler unit are harbor of wide range of
micro-organisms.

• They colonize and replicate on the inner surface

of tubings.

• They serve as reservoir for micro-organisms.

51
Following measures should be taken to prevent this :

A) Anti-retraction valves : (one way flow check valve). To prevent

transfer or aspiration of potentially infected material in the
tubings.

B) Bacterial filter : Filters to be fitted in water lines of hand-pieces

& water syringes.

C) Chemical Disinfectants : Tubings are flushed with disinfectants

like
sodium hypochlorite.

D) Aspirators : Cleaned and flushed after every patient for 20 – 30

secs.
52

To be flushed with disinfectant at the end of the day.

 Impression trays are sterilized as follows
metallic - autoclave
plastic – ethylene oxide

 Disinfection of alginate impressions –

Methods
- Spraying
- Immersion
Iodophors, sodium hypochlorite (1:10
concentration ) , phenols, formaldehyde, glutaraldehyde.
59
 DENTAL CASTS
CDC(MMWR),dec19,2003vol.52
 Spraying until wet  ADA recommends use of
or Immersing in a  Chlorine compounds
1:10 dilution of
sodium  Iodophors
hypochlorite or an  Combination of synthetic
iodophor then rinse phenols
 Casts to be disinfected  Glutaraldehyde.
should be fully set
(i.e. stored for at least
24 hours)

60
• Sterilize instruments like articulators, wax knives, spatula, shade
guide, acrylic bur etc.

• Custom impression trays, base plates, occlusal rim and all other
prosthesis must be disinfected, after construction & before use in
patient.

• Articulators, casts, base plates to be disinfected by 1:10 chlorine

solution following each session or before returning to laboratory.

• Dentures washed & soaked in sodium hypochlorite for 5 mins before

delivery.
55
 ROTARY INSTRUMENTS - BURS

 Diamond and carbide burs:

After use they are placed in 0.2%
gluteraldehyde and sodium phenate
(Eg. Sporicidin) for at least 10 minutes,
cleaned with a bur brush or in an
ultrasonic bath.
Sterilize in an autoclave or dry heat

 Steel burs:
May get damaged by autoclaving. Can be
sterilized by using a chemical vapor sterilizer or
glass bead sterilizer at 2300C for 20-30
seconds.

56
 ENDODONTIC INSTRUMENTS
CDC(MMWR),dec19,2003vol.52
• Glass Bead or salt sterilizer is the best option, but they do
not
sterilize the handle.
• Sterilization achieved in 10 seconds
• Dry heat is used, with instruments in closed metal or perforated
metal boxes.
• Sterilization achieved at 218oC for 15 seconds
• Gutta percha points are pre-sterilized.
• Contaminated points are sterilized 5.25% sodium
by
hypochlorite.(1 min immersion).
• Then rinse with hydrogen peroxide & dry 57

it.
• Silver cones sterilized by passing slowly over the flame for
3-4 times.

• Can also be sterilized in hot salt sterilizer.

• Files to be handled with tweezer.

• Glass slab is sterilized by swabbing the surface

with
tincture of thiomersal, followed by swabbing with alcohol.

• Cement spatula is sterilized by flamming 3 or 4 times over

bunsen flame.

58
HANDPIECE SURFACE
CONTAMINATION CONTROL

59
Sutures
 Sutures are pre sterilized by gamma radiation
 Sutures are re- sterilized by two recommeded methods are
1.Soak for a full 10 minutes completely immersed in
povidone iodine 10% solution, then rinse in sterile
saline/water.
2. Ethylene Oxide – gas sterilisation.

60
 ULTRASONIC SCALERS
CDC(MMWR),dec19,2003vol.52

 Soak inserts in a container containing 70% isopropyl alcohol

for removal of organic debris.
 Rinse cleaned inserts thoroughly in warm water to remove all
chemicals. As a final rinse, replace the insert into the scaler
handpiece and operate the scaler for 10 seconds at the maximum
water flow setting to flush out any retained chemicals
 Dry inserts completely with air syringe
 Package in proper wrap, bags, pouches, trays, or cassettes. Add spore
tests and chemical indicators.
 Ethylene Oxide is the preferred method of choice
 Dry heat and chemical vapor methods of sterilization are considered
ineffective methods with risk of damage to materials as per American
Dental association Supplement to J.A.D.A.
8/92. 61
Effect of sterilization on
instruments
Sterilization Type of instrument

Stainless steel Carbon steel

Saturated steam at 250°F Amorphous substance Dulling and oxidation of
formed near cutting edge; cutting surfaces
no dulling.
Formalin-alcohol vapor at Cracking of wire edge; no Some oxidation of
270°F dulling. surfaces; no dulling.
Dry heat at 320°F Chipping of wire edge; no No visual change.
dulling.
Dry heat at 340°F Chipping of wire edge; no No visual change
dulling.

Effects of Sterilization on Periodontal

Instruments Roger B. Parkes,* and Robert A.
Kolstadf Accepted for publication 31
August
1981 71
Recent advances in sterilization and
disinfection
 Various new methods of sterilization are under investigation and
development.

 Peroxide vapor sterilization - an aqueous hydrogen peroxide

solution boils in a heated vaporizer and then flows as a vapor
into a sterilization chamber containing a load of instruments at
low pressure and low temperature

 Ultraviolet light - exposes the contaminants with a lethal dose of

energy in the form of light. The UV light will alter the DNA of
the pathogens. Not effective against RNA viruses like HIV.

72
Plasma Sterilization
 Plasma is basically ionized gas. When you apply an
electric field to a gas, it gets ionized into electrons
and ions.

 Plasma is usually comprised of UV photons, ions,

electrons and neutrals.

 A plasma is a quasi-neutral collection capable

of collective behavior

 Their combined photolytic, chemical and

electric action efficiently kills most micro-
organisms.
Ozone
 Ozone sterilization is the newest low-temperature
sterilization method recently introduced in the US and is
suitable for many heat sensitive and moisture sensitive or
moisture stable medical devices

 Ozone sterilization is compatible with stainless steel

instruments.

 Ozone Parameters • The cycle time is approximately 4.5

hours, at a temperature of 850F – 940F.

74
 Newer Disinfectants
 Persistent antimicrobial-drug coating that can be applied to inanimate
and
animate objects containing silver (Surfacine)

 A high-level disinfectant with reduced exposure

time (ortho- phthalaldehyde)

 An antimicrobial drug that can be applied to animate and inanimate objects

(superoxidized water)
Reference
s
 Texbook of microbiology by Prof. CP Baveja.(3rd edition).
 Ananthanarayan and Paniker’s textbook of Microbiology.
(10th edition).
 Operative dentistry chp- infection control by Studervant.
(4th edition)
 Essentials of preventive and community dentistry
Soben peter (3rd edition)
 Textbook of clinical periodontology, Newman, Takei,
Carranza, 11th edition.
 WHO glossary
 Article on Sterilization of Suture material by Ingrid Cox
dated 2004 17(50) from Community Eye Health Journal.


111
 Sterilization and disinfection of dental instruments by
ADA
 Disinfection & sterilization of dental instruments TB
MED 266, 1995
 CDC, guidelines for disinfection & sterilization in
health care facilities 2008.
  Article on Sterilization of Suture
material by Ingrid Cox dated 2004 17(50) from
Community Eye Health Journal.
 Article on effects of sterilisation on periodontal
instruments by Roger B. Parkes and Robert A. Kolstadf
Accepted for publication 31 August 1981 Journ
Periodontology.

112