Chapter 4 Infection Control Pediatric Dentistry

Q Sterilization procedure for clinic? (RURS 2006)

Or

Q Infection control (RGUHS 2001)

Ans The concept of asepsis in the prevention of infection is the most important consideration
for the success of surgery, since infection is the greatest deterrent to the normal wound healing

Sterilization: is defined as the process by which an article surface or medium is freed of all living
organisms either in spore or vegetative state.

Disinfection: is defined as the destruction or removal of all pathogen organism or organisms

capable of giving rise to infection. Disinfectant is a chemical used on non vital object to kill
surface vegetative or pathogenic organisms but not necessarily their spore forms.

Antiseptic: It is a chemical that is applied to the skin or mucous membrane to reduce the number
of micro-organisms by inhibiting their growth or by destruction they may be bacteriostatic or
bactericidal.

Spesis:-It is the breakdown of living tissue by the action of micro-organisms and is usually
accompanied by inflammation.

Asepsis: It refers to the avoidance of sepsis.

Goal of sterilization:

After micro organism enters body, 3 basic factors determine whether an infectious disease will
develop. They are;

Virulence ( pathogenic capacity of micro organism)

Dose ( no. of micro organism that invade body)

Resistance( body defence mechanism of host)

Therefore the goal of infection control is to reduce the dose of micro organisms that may be
shared between individual or individuals and contaminated surface & increase the resistance of
the body. Thus more the dose of micro organism is reduced, the better are the chances for
preventing disease spread

It can be done by following ways;

Use of Procedures that minimize spraying or spattering of oral fluid (rubber dam, high volume
evacuation, mouth rinse)

Hand washing, surface pre cleaning & disinfection

Use of barriers like masks, gloves & protective eye wear & clothing

Proper disposal of waste

Agents used in sterilization:

They can be broadly be classified into two types:

PHYSICAL AGENTS

Sunlight

Drying

Dry heat- flaming incineration , hot air

Moist heat- pasteurization , boiling , steam under normal pressure , steam under pressure

Filtration -candles ,asbestos ,pads, membranes

Radiation
Ultrasonic and sonic vibrations

CHEMICAL AGENTS

Alcohol - ethyl, isopropyl, trichlorobutanol

Aldehydes - formaldehyde, glutaraldehyde

Dyes

Halogens

Phenols

Surface active agents

Metallic salt

Sunlight; It is natural bactericidal agent. It uses ultra violet light & heat ray to sterilize. It is not a
dependable mode. It causes sterilization of water tanks & rivers.

Acc. to Semple and grieg;

Typhoid bacteria when exposed to sunlight die in an hour

Laser can be used to sterilize files & reamers; it even kills spores in 3 secs

Drying: drying in air has deleterious effect on growth of bacteria, it does not affect the spore
form. It is an unreliable method

Heat:

It depends upon following;

Nature of heat
 Moist heat

Dry heat

Temperature & time

No. of micro organism

Characteristic of micro organism i.e. species, spores, strain etc

Moist heat:

Pasteurization: it can be done in two ways;

Holder’s method; heating at 63.C for 30 minutes

Flash method; heating 72.C for 15 minutes

Staphylococcus / streptococcus are destroyed at 60.C /30 min

Yeast & moulds are destroyed at 80.C / 5-10 min

Clostridia are destroyed at destroyed at 120.C/4 min.

Viruses are inactivated at temp. Above 60.C

Mycobacterium, brucellae, salmonella are destroyed

But Spore form are not destroyed

Boiling water sterilization

It is boiling water at normal atmospheric pressure to produce a temperature of 100 C

That kills many bacteria in 10 minutes but the spores may not be killed even in twenty four
hours.

A 2% solution of sodium carbonate can be added to elevate the boiling point of water to
improve the bactericidal effect.

Cutting instruments lose their sharpness by repeated boiling. However glove drains, catheters
and rubber tubing’s can be sterilized if boiled for fifteen minutes. Instruments must remain
dipped in water during boiling.

Steam sterilization or Auto calving:

It is the use of moist heat in the form of saturated steam under pressure. It kills micro organisms
by coagulation & denaturisation of their proteins

Steam sterilization involves heating water to generate steam in a closed chamber, producing a
moist heat that rapidly kills micro organisms.

It is the heat, not the pressure inside a steam sterilizer, is what actually kills the micro organisms
because in the absence of air in a closed system, the steam creates higher temperatures than
steam coming from an open pan of boiling water (at 212 F or 100 C).

The maximum steam temperatures are:

250 F (121.1 C) at 103kpa or 15 psi pressures for 15 minutes

126. C at 103kpa or 15 psi pressures for 10 minutes

Flash method:
273 F (134 C) at 206kPa or 30 psi pressures for 3 - 10 minutes

They work in four cycles:

1. The heat up cycle

2. The sterilizing cycle

3. The depressurization cycle

4. The drying cycle

Types of steam sterilizer:

Gravity steam sterilizer; steam pushes out the air in the chamber

Vacuum steam sterilizer; vacuum is used push out air prior to sterilization

Some sterilizers have post sterilization vacuum to facilitate drying

Some steam sterilizers pull in fresh air through a microbial filter (e.g., a high-efficiency
particulate air filter) at the end of the sterilization cycle to facilitate drying.

Other sterilizers have an automatic open door drying cycle.

Loading: All instruments and accessories are kept in packs, pouches, or cassettes, separated from
each other so that steam has access to all package surfaces.
Unloading: Drying of packages is done inside the steam sterilizer to maintain the sterility of the
instruments. Exposing wet packages to the environment outside the sterilizer also can cause
wicking which is the process that allows the bacteria and fungi to penetrate into the wet sterilized
wraps or paper pouches. Thus these packages should be dried inside the sterilizer before
handling them.

Advantages:

 time efficient

 can sterilize porous material such as linen, papers, cloth wrappers, cotton wool,
instruments, laboratory ware, media etc

Precautions:

 do not use closed containers

 damage plastic & rubber ( may melt)

 non stainless material corrodes

To prevent corrosion:

Ammonia

Decylamine or

2% sodium nitrate can be added

use of hard water may leave deposits

contamination if taken out quickly

Dry Heat Sterilization

Dry heat sterilization involves heating air, with transfer of heat energy from the air to the
instruments.

Types of dry heat:

1. Flaming

2. Incineration

3. Hot air oven

Flaming: it destroys vegetative organism. Inoculating loops or wires, points of forceps, scalpel,
glass slides Silver cones etc can be passed a few times through Bunsen flames.

Incineration: This is used to disinfect soiled dressing, bedding, bandages etc

Hot air oven:

It kills the micro organisms by dehydration & oxidation of their protein. In case of spore, steam
condenses on it, increases its water content, and causes hydrolysis and breakdown of bacterial
protein.

Dry heat sterilizers operate at 320 F to 375 F (160 C to 190 C). The advantage is that carbon
steel items do not corrode during sterilization. It is of two types:-

Static air

Forced air

Static-air type of heat sterilizer:

It is also called oven type of dry heat sterilizer

The heating coils in the bottom of sterilizer causes the hot air to rise inside the chamber this heat
energy from the static air is transferred to the instruments.

Cycle:

320 F (160 C) for 1 to 2 hours

Forced-air type of dry heat sterilizer:

It is also called rapid heat transfer sterilizer.

The sterilizer circulates the heated air throughout the chamber at a high velocity. This circulation
permits a more rapid transfer of heat energy from the air to the instruments, reducing the time
needed for sterilization.

Cycle:

375 F (190.C) for 12 minutes (wrapped)

375 F (190.C) for 6 minutes (unwrapped)

They are of two types:-

1) Continuous heating type : The chamber is preheated and instruments are kept in the
chamber. Sterilization starts when temperature reaches 375 F (190 C). Then instruments are
allowed to cool. It takes less time as air flows continuously.

2) Cold type heating: The chamber begins from cold start and sterilization begins when
temperature reaches 375 F (190 C). Then heating is stopped and then unit circulates air in
chamber to sterilize and then cools.

Advantages:

 No corrosion

 Short cycle

 Items are dry after cycle

 It can sterilize glass syringes, test tubes, pipettes, forceps, scissors, scalpels, oil, jelly,
powder, swab sticks. But can’t be used for plastic and rubber

Glass bead sterilization:

It uses glass bead or Salt mixed with Mg carbonate, Na silicoaluminate

Temp: 425 to 475. F or 218 to 246.C

Files, broaches & reamers for 5 sec

Paper points & cotton pellets for 10 sec

Unsaturated Chemical Vapour Sterilization:

It involves heating a special chemical solution in a closed chamber, producing hot chemical
vapours that kill micro organisms.

The unsaturated chemical vapour sterilizer is called Harvey sterilizer or Chemiclave.

The chemical solution contains-

Formaldehyde (the active ingredients) - 0.23%

Ethanol plus acetone, ketone, water, and other alcohols - 72.38%

One should protect the skin and eyes from contact with the solution and should not breathe in
vapours.

This sterilizer operates through four cycles:

1. The heat-up / vaporization cycle

2. The sterilization cycle

3. The depressurization cycle,

The Purge cycle.(optional)

Cycle:

270 F (132.C) at 25 psi pressure for 20 min

The heat-up cycle causes the chemical solution to vaporize, yielding a pressure of about 172kPa
(25 psi), and when the temperature reaches about 270 F (132 C), the sterilizing cycle begins. The
temperature is maintained for 20 minutes, and the chamber is depressurized, with a decrease in
temperature.

The purge system which is attached to the sterilizer recollects chemicals of the vapours in the
chamber at the end of the process. This system greatly reduces the smell from the chemicals

Advantages:

Time efficient

No corrosion

Items dry quickly after cycle

It reduces or eliminates corrosion of carbon steel instruments

The amount of water in the chemical solution used is below the level that causes corrosion. For
this reason, drying of instruments before processing them in this sterilizer is important.

It can be used to sterilize Paper, plastic peel pouches, bags, linens, textiles, fabrics, or other
absorbent materials such as paper towels. But can’t sterilize liquids & rubber

Oil sterilization

It is boiling & submersion of instrument in oil at a temperature of 175 C for 15 minutes for
sterilization
Hot oil baths are used for sterilizing metallic instrument like hand pieces

This method should not be used for sterilizing syringes and needles because of the risk of oil
embolism.

It has poor oil penetration properties, poor sporicidal activity & presents fire hazard

Cold sterilization:

Chemical agents are used for sterilization.

Alcohol

Benzalkonium chloride

Hexachlorophene

They are strong surfactant which increase the permeability of cell wall and help s in escape of
phosphorus and nitrogen and denatures protein

Heat sensitive instruments are dipped in alcohol (70 & 90% isopropyl) or 1:1000 solution of
Benzalkonium chloride for overnight immersion.

Hexachlorophene compounds kill all vegetative bacteria if the instruments are kept submerged
for three hours

They are less effective against spores.

They are used as anti septic and disinfectant & have limited gram + activity

They are used to disinfect floors & wall

Gas sterilization:

Three gases are used:

Ethylene oxide

Formaldehyde gas

Betapropiolactone

Ethylene oxide which is a gas at a temperature of 10.8 C for 6 to 12 hours under controlled
conditions of temperature, humidity and pressure destroys organisms by alkalisation of amino,
carboxyl, hydroxyl, & sulphydryl group of protein

It is inflammable so t is mixed with inert gases like carbon dioxide or feron

It is effective against tubercle bacilli viruses & spores

It provides an alternative effective method of sterilizing the heat sensitive and water sensitive
instruments, heart lung machine, surgical instrument, glassware, clothing, plastic, books, ryle’s
tube etc

It takes 1 – 7 days to degas objects like plastics.

Formaldehyde gas is used which is prepared by mixing KMnO4 & formalin

Formaldehyde tablets are also used for the sterilization of hand pieces, fumigation of operation
theatre, rooms etc., but it gives unpleasant odour.

Betapropiolactone:

It is also used for fumigation & is effective against viruses

Irradiation:

Two types of radiation are used:

Non ionizing radiation

Ionizing radiation

Ionizing irradiations:

Such as X-rays, gamma rays, accelerated beta rays.

They have high penetration power and are lethal to all cells including bacteria. Ionizing radiation
is used to sterilize disposable material such as needles, suture materials, cannulas, dressings,
catheters, syringes, plastic tubes, culture plates etc.

Gamma ray sterilizer

Non ionizing radiation: they are of low energy. Optimal wave length 2650 Armstrong is used

Infrared radiation: used for mass sterilization of syringes

Ultraviolet radiation: used to disinfect hospital wards, operation room, lab etc

Filtration:

It filters micro organism from heat labile liquids and substance such as sera, sugars and urea
which are used for preparation of media. They can also be used to filter viruses. They are of
following types:

Earthenware filters (ceramic, diatomaceous earth, doluton filter)

Asbestos filters (they are single of use. they are not used much because of carcinogenic potential)

Sintered glass filter(made up of heat fusing finely powered glass particle)

Membrane filter (made up of cellulose esters or other polymers. Pore dia- 0.22micrometer. Used
for water purification, analysis, sterility testing.)

Antiseptics and disinfectants:

Disinfectant is a chemical used on non vital object to kill surface vegetative or pathogenic
organisms but not necessarily their spore forms.

Antiseptic: It is a chemical that is applied to the skin or mucous membrane to reduce the number
of micro-organisms by inhibiting their growth or by destruction they may be bacteriostatic or
bactericidal.

Modes of action;

Chemical agents act by following ways:

Protein coagulation

Disruption of cell membrane

Removal of sulphadryl group which is essential for functioning of enzyme

Substrate competition i.e. misleads or divert enzyme for metabolism

Types of Antimicrobial chemicals :

Antibiotics (for killing micro organisms in or on the body)

Antiseptics (for killing micro organisms on the skin or other body surfaces)

Disinfectants (for killing micro organisms on environmental / inanimate surfaces or objects)

Sterilants (for killing all micro organisms on inanimate objects).

Virucidal (kills at least viruses)

Bactericidal (kills at least bacteria)

Tuberculocidal (kills the tuberculosis bacterium)

Sporicidal (kills bacterial spores, which means it is a sterilant)

Hospital disinfectant ( kills the three representative bacteria:

Staphylococcus aureus, Salmonella choleraesuis, and Pseudomonas aeruginosa)

The Centres for Disease Control and Prevention (CDC) have categorized disinfectants based on
their microbial spectrum of activity. The categorization follows and is described further:

Sterilants /high level disinfectants (for killing all micro organisms on submerged inanimate
objects that are heat sensitive)

Intermediate-level disinfectant (for killing vegetative bacteria, most of the fungi, viruses and M.
tuberculosis)
 Low-level disinfectant (for killing most vegetative bacteria, some fungi, and some viruses)

Categories of disinfecting sterilizing chemicals

Category Definition Examples Use

Glutaraldehyde, Heat-sensitive reusable
items:immersion only
Sterilant Destroys all micro
organism & Bacterial
spores hydrogen peroxide

with peracetic acid,

peracetic acid

Destroys all micro

organisms, but not Heat-sensitive reusable
High-level glutaraldehyde-phenate, items: immersion only
necessarily bacterial
disinfectant
spores hydrogen peroxide

Orthophthal aldehyde

Destroys vegetative
bacteria, most of fungi
and viruses, inactivates Hospital disinfectants
Intermediate- mycobacterium phenol, chlorine based
level tuberculosis products, iodophors, Clinical contact surfaces
disinfectant quaternary ammonium
compounds with alcohol
& bromides

Destroys vegetative
bacteria and some fungi
& viruses quaternary ammonium
compounds
does not inactivate Housekeeping
mycobacterium surfaces(e.g., floors, walls)
tuberculosis

Low-level
disinfectant

Alcohols:

Ethyl and isopropyl alcohol is used

They are used in conc. of 60-70% in water as skin anti septic. These are good organic solvents
and hence are good cleansing agents kills bacteria but have no action on spores

Used for antisepsis on skin prior to injection or needle puncture or disinfect thermometer

Hexachlorophene :

3% solution of hexachlorophene gives good results against gram positive organisms. It has been
used as surgical scrub for the preparation of the operative site.
Halogens:

They have bactericidal & germicidal action.

They are effective against bacteria, spores, tubercle bacillus, fungi & viruses etc

They are most effective skin antiseptics especially when iodine is complexes with organic
surface active agents like polyvinyl pyrrolidone.

Iodine, Sodium hypochlorite, chlorine are the examples

2% Tincture of iodine is used for application on oral wounds.

5% solution of Povidone Iodine (betadine) is used as microbicidal application on the skin prior to
surgery.

5.2% Hypo & H2O2 are used to sterilize Gutta percha

Tincture of thimersol is used to sterilize dappen dish & glass slab

They are also used for disinfecting the instruments and linen etc. especially after the surgery on
patients who are HIV positive

Aqueous quaternary ammonium compounds:

2% Benzalkonium chloride is the most commonly used antiseptic. It is well tolerated by living
tissues but it is primarily effective against gram positive bacteria only.

Hydrogen peroxide: An aqueous solution of 3% hydrogen peroxide is used. It is an oxidizing

agent and is effective against anaerobes. It liberates oxygen when it comes in contact with the
living tissues. It is used for irrigation of contaminated open wounds after diluting with equal
parts of water.
Phenols:

They are obtained by distillation of coal between temperatures 170-270.C

They cause cell membrane damage

They are powerful microbicidal and are used at conc. of 1%

They are effective against Gm + & - organism

Carbolic, Lysol, cresol, chlorhexidine are examples

They are used for disinfection of walls, floors and furniture etc. They are highly irritating to the
skin and mucosa.

Chlorhexidine 20%solution of chlorhexidine gluconate is used for rapid hand disinfection prior
to surgery. Whereas a 0.2% solution is used as an antiplaque agent & mouthwash

Aldehyde compounds:

They are bacteriocidal & sporicidal

It is active against amino group of protein molecule of bacterial cell wall

Formaldehyde & glutaraldehyde are example

They are used for heat sensitive instrument, fumigation of wards & OT, sick room, bedding ,
furniture, lenses of cytoscope, bronchoscope, endodontic micro scope, polythene tubing, face
mask, gloves etc.

Surface active agents:

They are also known as surfactants

They are bactericidal by altering interface energy. They have no action on spores

0.5% certimide (cetavalon) solution in isopropyl alcohol and purified water is used for washing
the skin wounds and skin preparation prior to surgery. It is also used for keeping the cheatle
forceps dipped while not in use

Soap are also active against Gram + & - organism

Dyes:

There are two groups

Aniline dyes

Acridine dyes

They are used as skin & wound anti septic

Brilliant green, malachite green, crystal violet,proflavine, acriflavine are examples

They are effect against Gram + & - organism

They are non irritant & non toxic

Pus inhibit their activity

Metallic salts:

They are salts of silver, copper, mercury

They are mild anti septic

Copper salts are fungicidal

They are used on ulcers. Skin grafts

Asepsis control:

At procedure time

Pre cleaning and surface covers

Touching as less surface as possible

Minimization of dental aerosol and spatter

High volume suction

Use of rubber dam

Mouth rinses

Use of disposables

Instrument processing:
 Holding (for pre soaking)

Pre soaking is done soon after use with detergents

Pre cleaning

It is done to reduce bio burden (micro organisms, blood, saliva and other materials). It is done by
ultrasonic cleaning

Packing

It is done to maintain the sterility of instrument. It is done by keeping in pouches, bags, trays and
cassettes.

Dentist protection

It is done by alcohol based hand rubs, gloves (disposable hand gloves for protection, heavy
utility for holding instrument).

Hand hygiene

Protective face mask

Protective eye wear

Protective body wear

Instrument cleaning cycle:

 Sterilization of Dental instrument & material

Material/Instruments Autoclave Hot air oven Chemical Ethylene

vapours oxide
Angle attachments G G G E

Burs

Carbon steel F E E E

Steel G E E E

Tungsten carbide G E G E

Condensers E E E E

Dapen dishes E G G E

Endodontic instruments E E E E
 broaches, files, reamers

condensers & pluggers

Stainless handles G E E E

Stainless handles with plastic handles E E F E

Fluoride gel trays

Heat resistant plastic E I F E

Non heat resistant plastic I I F E

Glass slabs E E E E

Hand instrument

Carbon steel F E E E

Stainless steel E E E E

Hand pieces E F G E
Contra angles E F E E

Prophylaxis instrument G G G G

Ultra sonic scaling tips

Impression trays

Aluminium metal E G E E

Chrome plated E E E E

Custom acrylic tray I I I E

Plastic tray I I I E

Instruments in packs E G G E

Instrument tray G G G E

Mirrors F E E E
Needles F I I I

Nose pieces/ Hoses E I E E

Orthodontic plier

High quality stainless steel E E E E

Low quality stainless steel F E E E

Polishing wheels & disks

Rubber items/ polishing cups

Prostheses F F F G

Rubber Dam equipment

Carbon steel clamps E E E E

Stainless steel clamps E E E E

Metal frames E F F E

Plastic frames F E E E
 punches F E E E

Surgical instrument

Saliva ejectors F F I F

Water-air syringe E E E E

X-ray equipments

Plastic film holder E I G E

Collimating device F I I E

Antimicrobial Spectrum of Some Hand Hygiene Agents

Agent Gram- Gram- Myco Fungi Viruses Speed of Comments

positive negative action
bacteria bacteria bacteria

Alcohols E E E E E Fast Optimum

concentration 60%-
90% ; no persistent
 activity

Persistent activity,
rare allergic
reactions

Chlorhexidine E G F F E Intermediate
(2% and 4%) Less irritation than
iodine

Neutralized by non-
Iodophors
ionic surfactants
E E F G G Intermediate

Accept-ability on
hands varies

Phenolics
E F F F F Intermediate
Used only in
combination with
alcohols

N
Triclosan
E G N E Intermediate
Quaternary N
ammonium
compounds F G N F Slow