STERILIZATION AND

DISINFECTION
Contents:
Definitions
Classification of instruments
Decontamination cycle
Sterilization and its methods
Principles of sterilization
Disinfection and its methods
Agents used for disinfection
Personal barrier protection
Conclusion
References
 Infection
is the process of invasion of the tissue by organisms
It
characterized by their multiplication in the body of the
host to produce disease.

Infection control:
In medical care, institutional procedures and policies
for monitoring and attempting to control the
transmission of communicable diseases.

This includes establishing mandatory sanitation,

sterilization, hand hygiene, and isolation procedures.
3
 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

 Standard Precautions
Apply to all patients

Integrate and expand Universal Precautions to

include organisms spread by blood and also
Body fluids, secretions, and excretions except
sweat, whether or not they contain blood
Non-intact (broken) skin
Mucous membranes
Universal precaution Vs Standard precaution

According to Centers for Disease Control, STANDARD

PRECAUTION is the outgrowth of UNIVERSAL
PRECAUTION (UP). Universal Precaution was first introduced
on 1987 to prevent the spread or the transmission of blood
borne pathogens to the health care providers. However, on
1996 the concept of standard precaution was established to
expand the course of universal precaution .

STANDARD PRECAUTION now constitutes the primary

strategy to prevent the transmission of infectious agents not
only to the health care personnel but also to patients and
hospital visitors.
 Cleaning
A process which removes visible contamination, but does
not necessarily destroy microorganisms.

Asepsis
The methods which prevent contamination of wounds and
other sites, by ensuring that only sterile objects and
fluids come into contact with them, and that the risks of
air-borne contamination is minimized.

Antisepsis
The prevention of infection, usually by inhibiting the
growth of bacteria in wounds or tissues.
 Antiseptics
Chemical disinfectants which can be safely applied to
skin or mucous membrane and are used to prevent
infection by inhibiting the growth of bacteria.

Decontamination
The process of rendering an article or area free of
danger from contaminant, including microbial,
chemical, radioactive and other hazards.
 Disinfection
Process which reduces the number of microorganisms
present, but may not inactivate some viruses and
bacterial spores.

Sterilization
Process that destroys, eliminates or inactivates (kills)
all forms of microbial life including bacterial
endospores.
 Depending on the risk of transmitting infection
instruments are classified as:

A. Critical :-(high risk)

Instrument that come in contact with Critical

surfaces such as Sterile tissue, body cavity,
bloodstream
instruments that penetrate soft tissue or bone
Enter sterile body cavity such as endodontic
microsurgical procedures
Should be sterilized
Eg. chisel, scalpel, forceps, burs, periodontal scalers
B. Semi critical :(medium risk)

Instruments that come in contact with semi critical

surfaces such as Intact oral mucosa, non-intact skin

contact with the oral tissue/body fluids such as

gingiva, teeth

if sterilization not possible than high level disinfection

Eg.- mouth mirror, explorer and amalgam condensers ,

air water syringe, dental handpieces
C. Non Critical :(low risk)

Instruments or medical devices that comes in contact

with the non critical surfaces such as intact skin.

Intermediate level or low level disinfection or

detergent and water washing

E.g. external components of x-ray head, chairs,

supporting equipment of dental unit, stethoscope
 DECONTAMINATION CYCLE

USE

STORAGE CLEANING

proper
sterilisation relies
on a combination
of processes
which together
STERILISATION form an infection DISINFECTION
control system

PACKAGING INSPECTION
Sterilization and its methods
3 most commonly used methods of sterilization are:
Steam autoclave
Dry heat oven (dryclave)
Unsaturated chemical vapour sterilizer(Chemiclave)

Other methods are:

Exposure to ethylene oxide gas
Boiling water
Ionizing radiation
 Principles of sterilization
All instruments should be thoroughly cleaned
Essential is that sterilizing agent should be in contact
with every surface of each item to be sterilized for
specified period of time at the specified temperature.

All sterilizing equipment should be regularly maintained.

Manufacturers instruction should be strictly adhered

to.
 Moist/ steam heat sterilization
(Autoclave)
PRINCIPLE:

Water boils when its vapor pressure equals that of the

surrounding atmosphere
Hence when pressure inside a closed vessel increases ,
the temperature at which it boils also increases.
Saturated steam has penetrative power
When steam comes into contact with a cooler surface, it
condenses into water and gives up its latent heat to that
surface.
 1600ml of steam
at 100C and 1 1 ml of water at Releases 518
atmospheric 100c calories of heat
pressure

This large reduction in volume sucks in more steam to

the area & the process continues till the temperature of
that surface is raised to that of the steam

The condensed water ensures moist conditions for

killing the microbes present
 Types of autoclave:

1) Downward (gravitation)
displacement sterilizer

2) Steam sterilizer with pre and

post vacuum processes
Phases of Sterilization :

1. Pre-treatment phase/heat up cycle: All air is expelled

by a number of pulses(at least 3) of vacuum and
introduction of steam.

2. Sterilizing phase/Sterilization cycle: Temperature is

increased sufficiently at which sterilization is to take
place.
. Actual sterilizing period is called Holding/plateau time,
starts when the temperature in all parts of the
autoclave chamber and its content has reached the
sterilizing temperature.
3. Post treatment phase / depressurisation cycle and
drying cycle: Steam or revaporized condensed
water is removed by vacuum to ensure that the
goods are dried rapidly.

Time,temperature and pressure for autoclaving are :

Pressure (Psi) Temperature (C) Time(mins.)

15 121 15
20 126 10
30 134 3
 Packaging and marking of packs
Done before sterilizing to prevent instruments from being
contaminated after sterilization till it is opened and used.

Autoclave packaging should be porous to permit steam to

penetrate and reach the instruments. Eg. Fabric, paper,
muslin cloth pouches, nylon bags etc.

Packs should have some external indication, showing the

packs have been processed in form of marking.

Each pack must be labeled with content, date of

sterilization, autoclave number, load number.
ADVANTAGES

Most rapid and effective method of sterilization.

Provides excellent penetration.

DISADVANTAGES

Corrosion of carbon steel instruments.

May damage plastic and rubber items.
Unprotected cutting edges may become dull.
Dry heat sterilization (Dryclave)
It effectively sterilizes instruments at high
temperature above 160C.

Basic action involves dehydration and oxidation of

microorganism.
Achieved by 2 methods:

1) Dry heat oven type sterilizer(static air):

-160 C for 60-120 mins

2) Dry heat-rapid heat transfer(forced air):

- 6 mins for unwrapped instruments at 190 C.

-12 mins for wrapped instruments at 190 C.
Advantages:
Rapid cycles are possible at high temperature.

Burs &carbon steel instruments do not rust if they

are well dried before sterilization.

Large load can be placed.

Low cost of equipment.

Disadvantages:
Heat sensitive items like rubber or plastics may be
damaged.

At lower temperature ,sterilization cycles are

prolonged.

Sterilization is ineffective if there is heavy

instrument load and crowding.
 Unsaturated chemical vapour
sterilizer (Chemiclave)
This sterilizer is same as autoclave

unlike it uses special chemical solution

containing formaldehyde and alcohol.

The chemical vapour kills

microorganisms by destroying vital

protein systems.

STERLIZATION CYCLE FOR CHEMICLAVE:

Temperature (C) Pressure(Ibs) Time(minutes)

132 20 20
Advantages:
It does not corrode metals.

Load comes out dry.

Disadvantages
High cost of equipment.

Vapour odor may be offensive and requires increased

ventilation.

The solution supplied by manufacture has to be used.

Handpieces cannot be sterilized by this method.

ETHYLENE OXIDE STERILIZATION

It is an excellent sterilizer of heat sensitive items as

well as ideal for electric equipment ,flexible fiber
endoscopes and photographic equipment.

This method uses automatic devices filled with

ethylene oxide gas at temperature below 100c to
sterilize complex and delicate materials.

Ethylene oxide destroys microorganisms by chemically

reacting with nucleic acid.
Advantages :

Most gentle for sensitive equipment like hand pieces.

Operate effectively at low temperature.

Disadvantages:

High cost.
Prolonged time.
Best for hospitals not practical for dental clinics
Ethylene oxide gas is potentially mutagenic and
carcinogenic.
 BOILING WATER
Boiling water produces temperature of 1000c at normal
atmospheric pressure which requires 10 mins exposure
to kill bacteria and some viruses.

When the water starts boiling instruments should be

kept in it and should be fully immersed in it for 20-30
minutes.

Cutting instruments should not be sterilized by boiling

as they loose their sharpness.
 IONIZING RADIATION

It is effective for heat labile items .

It is commonly used by industry to sterilize

disposable materials such as needles, syringes, swabs,
catheters, suture material, cannulas.

High energy gamma rays from cobalt 60 are used to

sterilize such article.
 If autoclave is not available???

Place all instruments in water immediately after use.

Remove all debris from the instruments by scrubbing with

brush in soapy water.

Prepare fire with fuel available.

Put clean instruments in a pressure cooker and add clean water

in it.

Place the pressure cooker on the stove and bring it to boil.

Continue heating the pressure cooker on low heat for a

minimum of 15 minutes.
Ensure that steam continues to be released from pressure
cooker during this time

Remove pressure cooker from stove after 15 minutes and

leave it to cool.

Release pressure first before opening the pressure cooker.

Take instruments out of pressure cooker with instrument

forceps and dry in clean towel.

Store in a covered box(metal box).

 DISINFECTION

Disinfection is a process by which microbes

are removed from an object or surface. This
does not include bacterial endospores. This
process is used to treat articles which do not
penetrate the mucous membrane or skin.
Classification of disinfectants

1. Based on consistency
a. Liquid (E.g.Alcohols, Phenols)
b. Gaseous (Formaldehyde vapor, Ethylene oxide)

2. Based on spectrum of activity

a. High level
b. Intermediate level
c. Low level
3. Based on mechanism of action

a) Action on membrane (E.g.Alcohol, detergent)

b) Denaturation of cellular proteins (E.g.Alcohol, Phenol)

c) Oxidation of essential sulphydryl groups of enzymes (E.g.

H2O2, Halogens)

d) Alkylation of amino-, carboxyl- and hydroxyl group

(E.g.Ethylene Oxide, Formaldehyde)

e) Damage to nucleic acids (Ethylene Oxide, Formaldehyde)

 The two methods of achieving disinfection are:
thermal and chemical disinfection.

1. Thermal disinfection (pasteurization)

. By using heat and water at temperatures that destroy

pathogenic, vegetative agents

.Level of disinfection depends on the water temperature

and the duration the instrument is exposed to that
temperature
2. Chemical Disinfection

.The performance of chemical disinfectants is dependent

on a number of factors including: temperature, contact
time, concentration, pH, presence of organic or inorganic
matter and the numbers and resistance of the initial
bioburden on a surface.

.Chemical agents used are:

.Aldehyde (formaldehyde, glutaraldehyde)

.Biguanides (chlorhexidine)
.Halogens (sodium hypochlorite solution)
 2% Glutaraldehyde
Is generally the most appropriate high level
chemical disinfectant.
Active against most vegetative
bacteria(including M. tuberculosis) and some
viruses including HIV ,fungi and bacterial
spores.
Can be safely used on metal instruments
(< 24 hrs ), rubber, plastics and porcelain.
An immersion time of
20 min - disinfection
6-10 hours - sterilization
Must be used under very strict controlled
conditions and in a safe working environment.
 Biguanides (Chlorhexidine)

It is active against bacteria but

not spores, fungi and viruses.

0.5% chlorhexidine in 70%alcohol

is used
 Halogens (sodium hypochlorite solution)

Active against
bacteria,spores,fungi and
viruses including hepatitis
viruses.

1:10 freshly prepared sodium

hypochlorite solution is an
effective surface
disinfectant.
 Alcohols

Antibacterial activity against some Gram -ve, some

Gram +ve bacteria (especially against M. tuberculosis),
not effective against spores, viruses

It acts by denaturing proteins

70% alcohol is most effective than high concentration

Dont function as disinfectant when simply wiped

(must have minimum of 10 minutes contact)
 STERILIZATION OF HANDPIECES

While using hand pieces in patients mouth, blood, saliva, tooth

cutting debris and restorative materials may be drawn into its
working portion. Hence it should be properly sterilized between
patient exposure to prevent cross infection.

PROTOCOL FOR STERILIZING HANDPIECES

Clean the handpiece by wiping visible debris using suitable

disinfectant such as alcohol.

Run it for minimum of 30 seconds to discharge residual

water and air.
 Clean it thoroughly with soap and detergent solution.

Reattach handpiece to the unit and run dry.

Lubrication of handpiece should be done before

sterilization using lubricant.

Finally place the instruments in paper pack and seal it.

Now handpiece can be sterilized by autoclaving.

INSTRUMENT PROCESSING
 Categories of Environmental Surfaces

1.Clinical contact surfaces

High potential for direct contamination from spray or
spatter or by contact with DHCPs gloved hand

Risk of transmitting infections greater

Surface barriers can be used and changed between

patients

Clean then disinfect using an EPA-registered low-

(HIV/HBV claim) to intermediate-level (tuberculocidal
claim) hospital disinfectant
2. Housekeeping surfaces

Do not come into contact with patients or devices.

Limited risk of disease transmission.

Routinely clean with soap and water or an EPA-registered

detergent/hospital disinfectant.

Clean mops and cloths and allow to dry thoroughly before

re-using.

Prepare fresh cleaning and disinfecting solutions daily

and per manufacturer recommendations.
Categories of task in relation to risk

Category I

Tasks involving exposure to blood, body fluids and

tissues

Most tasks performed by the dentist, dental

hygienist, dental assistant and laboratory technician
falls in this category
Category II

Tasks that do not involve routine exposure to blood,

body fluids or tissues

Clerical or non-professional workers who may help to

clean up the office, handle instruments or impression
materials or send dental instruments to laboratory
fall in this category
Category III

Tasks that involve no exposure to blood, body fluids or tissues

Front office receptionist, book-keeper or insurance clerk who

doesnt handle dental instruments and materials

The American Dental Association(ADA) and

Occupational Safety and Health Act(OSHA)
guidelines advise that all dental office staff in
category I and II be trained in infection control to
protect themselves and their patients.
 OSHA regulation

Occupational safety and health administration(OSHA) is

federal agency that establishes regulation to protect
employees from unsafe working condition.

They are:

Employers must provide HBV immunization to employees

without charge within 10 days of employment.

Employers must require that standard precaution to be

observed to prevent contact with blood and other
potentially infectious materials.
Employers must implement engineering controls to
reduce production of contaminated spatter, mists and
aerosols.

Employers must implement work practice control

precautions to mimimize splashing, spatter, or contact
of bare hands with contaminated surfaces.

Employers must provide facilities and instruction for

washing hands after removing gloves.

Employers must prescribe safe handling of needle or

other sharp items.
Employers must prescribe disposal of single use needles,
wires, carpules and sharps as close to the place of use as
possible, as soon as feasible, in hard walled, leak-proof
containers that are closable, from which needles cannot be
easily spilled.

Contaminated reusable sharp instruments must not be

stored or processed in manner that requires employees to
reach hands into containers to retrieve them.

Employers must prohibit eating, drinking, handling contact

lenses and application of facial cosmetics in contaminated
environments, such as operatories and clean up areas.
Blood and contaminated specimens to be shipped,
transported or stored should be placed in suitable closed
containers that prevent leakage.

Employers must provide a written schedule for cleaning and

decontaminating equipment, work surfaces and contaminated
floors.

Place reusable contaminated sharp instruments into a basket

in hard walled container for transportation to clean up areas.

Employers must provide laundering of protective garments

used for universal precautions at no cost to employers.
Personnel Health Elements of an Infection
Control Program
Education and training

Immunizations

Exposure prevention and post-exposure management

Medical condition management and work-related

illnesses and restrictions

Health record maintenance

Personal barrier protection in the community
Gloves

Medical gloves(latex or vinyl)

must always be worn when there
is potential for contacting blood,
blood contaminated saliva or
mucous membrane

Nonsterile gloves for examination

and nonsurgical procedures and
sterile gloves for surgical
purposes
Must not be washed or used for more than one patient

Washing of gloves may cause wicking effect

Disinfecting agents, oils, certain oil-based lotions and heat

treatment may cause deterioration of gloves

While cleaning and sorting used instruments, puncture

resistant utility gloves should be worn which can be washed
inside out, disinfected or steam autoclaved as needed
While the Center for Disease Control recommends using
a new pair of gloves in the medical field for every use,
some situations such as a shortage of gloves or an
emergency may require multiple uses of gloves.

In this case, it is imperative that gloves are

appropriately disinfected using a specific procedure to
avoid passing along germs, pathogens, infections or even
diseases.
Instructions:
Grab the cuff of one of the gloves to turn inside out
and pull halfway off of the hand. Pull the other glove at
the cuff to turn inside out and pull halfway off the
hand.

When both gloves are halfway off the hands, pull both
gloves off from the inside at the same time. Never
touch the outer portion of the gloves with your skin.

Soak the gloves in 0.5 percent chlorine solution for at

least 10 minutes.
Wash gloves in soapy water inside and out and rinse fully.
Test for holes or tears by placing the gloves under water.
If any air bubbles appear, throw the gloves away
immediately. If no air bubbles appear, let the gloves air
dry.
Turn the cuffs of the gloves inside out a few inches and
place five to fifteen pairs of gloves onto each steamer pan
and cover with the lid.

Steam the gloves for 20 minutes at a rolling boil.

Air dry the gloves in the steamer pan for four to six hours
before use and remove with forceps into a disinfected
container with a lid.
 Instructions for handwashing

At the beginning of a routine treatment

period, remove watches, jewelry and rings
then wash hands with suitable cleanser

Hands should be lathered for at least 10

seconds rubbing all surfaces and rinsed

Washing should be repeated at least once

to remove all soil
Even good quality surgical gloves develop minor pinholes or
leaks during vigorous use.

Washing minimizes infection risks secondary to leakage.

Hand cleansers containing mild antiseptic like 3%

parachlorometaxylenol (PCMX) or chlorhexidine are
preferred to control transient pathogens and to suppress
overgrowth of skin bacteria.

Alcohol rubs are also effective against pathogens with

less drying effect.
CDC recommends the Dental Health Care
Worker(DHCW) who have exudative lesions or weeping
dermatitis particularly on the hands, should refrain
from all direct patient care and from handling dental
patient care equipment until the condition resolves.
Hands need to be cleaned when:
Visibly dirty

After touching contaminated

objects with bare hands

Before and after patient

treatment (before glove
placement and after glove
removal)
 When water and soap are not available,
Using hand sanitizer is a good substitute, but it's best
when you really know how to use it properly.

Composition of hand sanitizer

Active ingredient:
Isopropanol, ethanol, n-propanol or
Povidone iodine.
Inactive ingredient:
Poly-acrylic acid as thikening agent
Humectants like glycerin or propylene
glycol
Essential oil of plants
 Here are some easy steps to follow to make sure
that you do it correctly:

Step 1
Squirt the hand sanitizer into the palm of your hand.
Step 2
Start rubbing your hands
together gently. Be sure to get
every spot and not miss any
part. Get in between fingers,
under rings and under jewelry.
Rub hand sanitizer thoroughly
on hands and about two inches
up your wrist. Hold hands
downward to avoid
contamination on the upper
part of your arms.
Step 3
Finish. Don't dry your hands on a towel; it will be better
to let them air dry.
How to make your own hand sanitizer?
2/3 cup 99% rubbing alcohol (isopropyl alcohol) or
ethanol
1/3 cup aloe vera gel
8-10 drops essential oil, optional (such as lavendar,
vanilla, peppermint, grapefruit)
bowl and spoon
funnel
recycled liquid soap or hand sanitizer bottle
Simply mix the ingredients together and then use the
funnel to pour them into the bottle. Screw the pump back
onto the bottle and it can be used.
 Protective eyewear, masks and hair
protection
Protective eyewear consists of
goggles or glasses with solid
side-shields

Put eyewear with clean hands

before gloving and remove with
clean hands after gloves are
removed

Mask should be worn to protect

against aerosols
Grasp the mask only by the string or band at the sides or
back of the head to remove it

Mask should be changed between every patient or

whenever it becomes moist or visibly soiled

Should be discarded when patient is dismissed after

treatment instead of wearing it around the neck

Hair should be kept back out of the treatment field

Hair can trap heavy contamination which if not washed

away can cause cross contamination
Protective overgarments
Protective clothing such as reusable
or disposable gowns, laboratory coats
or uniforms worn when clothing is
likely to be soiled with blood and
other body fluids

Reusable protective clothing washed

using a normal laundry cycle
according to instructions of
manufacturer and detergent
 CONCLUSION
Pervasive increases in serious transmissible diseases over the
last few decades have created global concern and impacted
the treatment mode of all dental health care workers.

The aim of sterilization and infection control is to control

iatrogenic, nosocomial infections among patients and potential
occupational exposure of care providers to microbes causing
disease during provision of care.

To prevent occupational exposure and cross-infection dental

health care provider must be knowledgable about the
diseases commonly encountered and follow high standards of
infection control for the safety of patients and dental health
care workers.