Chapter 13: Intrument Processing

Copyright © 2017, Elsevier Inc. All Rights Reserved.
Instrument Processing
Chapter 13
1

Learning Objectives
Lesson 13.1: Instrument Processing
Procedures
1. Differentiate between sterilization and
disinfection; differentiate between critical,
semicritical, and noncritical patient care
items and describe differences in how such
items are processed; and define sterility
assurance.
2

2. Do the following regarding instrument
processing procedures:
• List the steps involved in instrument
processing and describe the rationale for each
step.
• Describe the three methods for instrument
cleaning and the techniques for performing
this task safely.
• Determine which packaging materials are
used for which methods of sterilization.
Learning Objectives
Lesson 13.1: Instrument Processing
Procedures (Cont.)
3

Introduction
 Instrument processing is a collection of
procedures that prepares contaminated
instruments for reuse
 Processing must be performed carefully:
 To prevent disease agents from a previous
patient, from a member of the dental team, or from
the environment from being transferred to the next
patient
 To keep instrument damage to a minimum
 The overall process consists of seven steps
4

CDC Health Advisory
 CDC has developed new sterilization-related
guidelines for dentistry, including:
 To have the manufacturer instructions for
reprocessing reusable dental
instruments/equipment readily available
 To label sterilized items
 To ensure routine maintenance
 In the Fall of 2015, the CDC and FDA issued
an official Health Advisory emphasizing the
importance of proper instrument processing.
5

Seven Steps to Instrument Processing
 Holding (presoaking)
 Precleaning
 Corrosion control, drying, lubrication
 Packaging
 Sterilization or high-level disinfection
 Sterilization monitoring
 Handling processed instruments
 Although the steps are not particularly difficult
to perform, each must be performed properly
in a routine, disciplined manner to ensure the
desired outcome of patient protection with
minimal instrument damage.
6

Sterilization and Disinfection
 Microbial killing methods
 Sterilization
• Process intended to kill all microorganisms; the highest level of
microbial kill that can be achieved
• Because routinely determining whether a microbial killing process
actually kills all microorganisms is not possible, a highly resistant
microorganism is selected as the standard challenge in
sterilization.
 Disinfection
• Less lethal process than sterilization; intended to kill disease-
producing microorganisms but not bacterial endospores
• Disinfection usually refers to the use of liquid chemicals to kill
microorganisms at room temperature on surfaces.
• If the chemical is not sporicidal but can kill other microorganisms,
it is called a disinfectant.
7

 What does sporicidal mean?
 It means “able to kill high levels of bacterial
endospores.”
8

Three Types of Sterilization
 Heat sterilization
 Most common
 Gas sterilization
 Not used often
 Liquid chemical sterilization
 Used on items damaged by heat sterilization
9

Three Types of Sterilization
 Other types of sterilization procedures exist,
but they have not been applied to the field of
dentistry or have not yet been made practical
for use in the dental office.
 Heat sterilization, which involves steam, dry
heat, and unsaturated chemical vapor, is the
most common type of sterilization used in
offices today.
 Glutaraldehyde is a commonly used liquid
chemical sterilant.
10

Categories of Patient Care Items
 CDC categorizes patient care items as:
 Critical
• Critical and semicritical items are to be cleaned and sterilized by
heat.
 Semicritical
• Semicritical items that are heat sensitive must, at a minimum, be
cleaned and treated with a high-level disinfectant.
 Noncritical
• Noncritical items are cleaned and treated with a low-level
disinfectant (if no blood is visible on the item) or an intermediate-
level disinfectant (if blood is visible).
 The classification is based on the potential risk of
infection during use of the items
11

Sterility Assurance for
Patient Protection
 Universal sterilization: All reusable
instruments and handpieces are sterilized
(rather than just disinfected) between uses on
patients
 This provides the highest level of patient
protection
 Sterility assurance: The correct performance
of the proper instrument processing steps
and monitoring of the sterilization step with
biological, mechanical, and chemical
indicators
12

 If an item used in the patient’s mouth cannot be
sterilized, cannot withstand the conditions of
sterilization, or cannot be prevented from becoming
contaminated during use, the item should not be
used or should be discarded after use on one
patient.
 Because the sterility of each processed instrument
cannot be measured routinely, one must depend
on the reliability of the instrument processing
procedures being performed.
 Maximum patient protection with universal
sterilization can be achieved only by practicing
sterility assurance.
13

Patient Protection (Cont.)
 Steps to sterility assurance
 Select the proper procedure and confirm the correct way to
perform that procedure
 Prepare a written step-by-step description of the correct
procedure to be used as a reference in training and to
document patient safety techniques used in the office
 Incorporate the procedure into the office training program
to ensure that new employees learn the correct procedure
 Monitor the performance of the procedure to ensure its
routine use and, when possible, measure the results of the
procedure
14

Patient Protection (Cont.)
 The statement “instruments have been
sterilized” is true only if sterility assurance is
practiced.
 Sterility assurance requires showing by
frequent biological, mechanical, and chemical
monitoring that the process used kills
bacterial endospores.
15

Instrument Processing Procedures
 Put on heavy utility gloves, protective
eyewear, mask, and protective clothing
 Remove gross debris from instruments by
wiping at chairside
 Take great care to avoid sharps injuries
 These barriers provide personal protection
from contaminants on the instruments and
from chemicals used.
 Wiping aids cleaning but must be performed
carefully.
16

Instrument Processing Procedures (Cont.)
 Place loose, contaminated instruments in
ultrasonic cleaning basket or washer basket
and place basket in holding solution until ready
to clean thoroughly. If using cassettes, remove
and dispose of waste and rinse
cassette/instruments with water
 Remove basket of instruments from holding
solution, rinse with minimum splashing, and
place in ultrasonic cleaner or washer, or place
cassettes in cleaning rack and place in
ultrasonic cleaner or washer
17

(Cont.)
 Extended presoaking for more than a few
hours is not recommended because this
enhances corrosion of some instruments.
 The first step shown here aids the
subsequent cleaning process by removing
gross debris.
 Using baskets or cassette racks facilitates
cleaning and reduces the direct handling of
the instruments and cassettes.
18

 Be sure ultrasonic cleaning unit or washer has been
filled to proper level with cleaning solution
 Place cover on ultrasonic cleaner or close washer
door and operate for the time recommended by the
cleaning unit manufacturer or cassette manufacturer
 Using the appropriate amount and type of cleaning
solution ensures the best cleaning.
 Thorough cleaning requires the appropriate amount
of time. In general, these times are 4 to 16 minutes
in ultrasonic cleaners.
 The time is set automatically in washers.
19

 Remove cleaning basket or cassette rack
from ultrasonic units and rinse under tap
water with a minimum of splashing. Rinse
cassettes individually and thoroughly
 Check instruments for broken tips and
cleanliness, and dry loose instruments with a
towel or let cassette drain. Replace or reclean
items as needed. Apply rust inhibitor as
needed for nonstainless items to be
processed in steam
20

(Cont.)
 Rinsing removes the residual cleaning
solution that contains microbes.
 Rinsing is usually automatic in washers.
 Checking instruments helps monitor the
effectiveness of the cleaning process and
determine when cleaning equipment repair
may be needed.
21

 Place instruments into functional sets or add
desired items to cassettes, including the
appropriate biological and internal and
external chemical indicators
 Use packaging material that is compatible with the
method of sterilization
 Sterilize following manufacturer’s
recommendations for loading, sterilizing time,
temperature, and drying
22

 Indicators monitor the effectiveness of the
sterilization process, and packaging maintains the
sterility of the instruments after they are removed
from the sterilizer.
 Sterilizers must be operated at the proper time and
temperature for sterility assurance.
 Seal the package or wrap the cassette and label for
content identification and sterilization date.
 Make sure chemical indicators are present or visible
on the outside of the packages.
23

 Carefully remove items from the sterilizer but
wait until after the dry cycle with steam
sterilizers
 Observe external chemical indicators for
proper reaction; retrieve biological indicators
for analysis; observe internal chemical
indicators; and store or distribute packages to
chairside with minimal handling
24

 Exposing wet packs after steam processing to
the external environment facilitates wicking
and contamination of the internal contents.
 Handling of wet packs after steam processing
also can tear the packaging material.
 Chemical monitors give an immediate
indication of instrument safety. Biological
indicators show the main guarantee of
instrument safety. Careful handling of sterile
packs prevents tearing and helps maintain
sterility.
25

Instrument Processing Procedure
 Maintain sterility assurance records on date and
conditions of sterilization and results of mechanical,
biological, and chemical indicators
 Sterilize reusable heat-labile items (e.g., some
plastic items) in a liquid sterilant, rinse, and package
in clean packaging material
 Maintaining sterilization monitoring records
documents compliance with rules and
recommendations relating to patient safety.
 Sterilization monitoring records document the
performance of proper instrument sterilization and
establish accountability in assurance of patient
safety.
26

Three Methods for Instrument Cleaning
 Ultrasonic cleaning
 Instrument washers
 Manual scrubbing of instruments
27

Ultrasonic Cleaning
28
Figure 13.2 shows ultrasonic cleaning. Instruments are placed
in an ultrasonic cleaning basket, and the basket is placed in the
cleaning solution.
Ultrasonic cleaning units come in several sizes that are
freestanding or can be built into countertops.

Ultrasonic Cleaning
 Reduces direct handling of contaminated instruments
 Excellent cleaning mechanism; staff can do other tasks
while instruments are being cleaned
 Always follow manufacturer’s directions for proper use.
 Use a cleaning solution designed for use on dental
instruments and recommended for use in ultrasonic
cleaners.
 Drain or discard the cleaning solution at least daily,
earlier if visibly soiled.
 The functioning of ultrasonic unit can be tested using
the aluminum foil test.
 See Figure 13.3.
29

Instrument Washers
30
Figure 13.4, A shows a benchtop model of an instrument washer holding 3
cassettes or baskets of instruments.
Instrument washers, like ultrasonic cleaners, remove bioburden and
reduce the direct handling of instruments using cassettes or baskets.

Instrument Washers
31
Figure 13.4, B shows a floor model holding 6 cassettes and baskets of instruments or
11 cassettes. C shows a large production model holding 36 cassettes.
Household dishwashers should not be used to clean contaminated instruments. They
are not designed for this purpose.

Manual Scrubbing of Instruments
 A dangerous, but effective, method of removing
the debris
 Use of a long-handled brush recommended to
keep hands far away from the sharp instruments
 Routine manual scrubbing is not recommended
because it requires maximum possible contact
with contaminated instruments.
 This increases chances for cuts or punctures
through the gloves.
32

Corrosion Control,
Drying, and Lubrication
 Instruments or portions of instruments and burs made of
carbon steel will rust during steam sterilization
 Instruments processed through a steam sterilizer should
at least be shaken to remove excess water or dried more
thoroughly if they will be packaged in paper or paper-
plastic sterilization wrap
 Hinged instruments should be opened before packaging
 Examples include nonstainless steel cutting or scraping
instruments such as burs, scalers, hoes, hatchets, the
cutting surfaces of orthodontic pliers, and the grasping
surfaces of forceps.
33

Packaging
 Maintains sterility after instruments have
been processed in sterilizer
 Involves wrapping cleaned instrument
cassettes and organizing cleaned loose
instruments in functional sets and placing
them in sterilization pouches or bags
34

 Packaging instruments before processing through
the sterilizer prevents them from becoming
contaminated after sterilization during storage or
when being distributed to chairside.
 Unpackaged instruments are exposed completely to
the environment immediately after the sterilizer door
is opened and can be contaminated by dust or
aerosols in the air, by contact with moisture, by
improper handling, or by contact with contaminated
surfaces.
 Numerous styles of cassettes are available that
contain functional sets of instruments during use at
chairside and during the precleaning, rinsing, and
sterilizing processes.
35

Packaging (Cont.)
36

Unwrapped Instruments
 Sterilizing unpackaged instruments using short
exposure times (flash sterilization) is least
satisfactory approach
 CDC recommends this not be used as a routine
sterilization procedure for patient care items
 A carefully written protocol for minimizing the risk
of post-sterilization contamination of unpackaged
instruments should be prepared and strictly
followed.
 Every flash sterilization cycle should be
monitored with mechanical, chemical, and
biological monitors.
37

Learning Objectives
Lesson 13.2: Sterilizing Instruments
3. Describe the physical conditions,
advantages, and precautions related to
steam, dry heat, and unsaturated chemical
vapor sterilization.
4. Compare the three methods of sterilization
monitoring, describe how to perform each
method, and describe what causes
sterilization failure and what to do when
failure is detected.
5. Describe how to handle, store, and distribute
sterilized instruments to maintain sterility.
38

Learning Objectives
Lesson 13.2: Sterilizing Instruments (Cont.)
6. Describe the factors to consider when
designing a sterilization facility within a
dental office.
7. List considerations of infection control when
sharpening instruments and tips for
protecting dental instruments.
8. Describe how to sterilize handpieces and
heat-sensitive instruments.
9. List other methods of sterilization and
properties of decontamination and
sterilization equipment and products.
39

Types of Sterilization
 There are three common types of sterilizers
used in dental offices
 Steam sterilization involves heating water to
generate steam in a closed chamber, producing a
moist heat that rapidly kills microorganisms
 Unsaturated chemical vapor sterilization involves
heating a special chemical solution in a closed-
chamber, producing hot chemical vapors that kill
microorganisms
 Dry heat sterilization involves heating air with
transfer of heat energy from the air to the
instruments
40

Types of Sterilization
 See Table 13.3 for the comparison of the three
most common types of sterilizers used in dental
offices.
 Most metal hand instruments and equipment can
be sterilized in any of these three sterilizers.
 Dry heat sterilization requires higher temperatures
than steam or unsaturated chemical vapor
sterilization.
 What is wicking?
 The process that allows bacteria and fungi to penetrate
wet sterilization paper
41

Steam Sterilizers
42
Figure 13.8 shows examples of steam sterilizers. A shows a unit
with cylindrical chamber. B shows a unit with a removable chamber
(cassette).
It is the heat, not the pressure inside a steam sterilizer, that kills the
microorganisms.

Unsaturated Chemical Vapor Sterilizer
43
Figure 13.13 shows an unsaturated chemical vapor sterilizer.
Unsaturated chemical vapor sterilization involves heating a special chemical
solution in a closed chamber, producing hot chemical vapors that kill
microorganisms.
This type of sterilization greatly reduces corrosion of carbon steel instruments.

Sterilization Monitoring
 There are three common types of monitoring
used in dental offices:
 Biological monitoring uses live spores
 Chemical monitoring uses chemicals
 Mechanical monitoring uses observation of
gauges
44

Biological Monitoring
 See Procedure 13.2 for detailed steps for
biological monitoring.
 Biological monitoring (also called spore
testing) provides the main guarantee of
sterilization. This involves processing highly
resistant bacterial spores through the
sterilizer and then culturing the spores to
determine whether they have been killed.
45

Chemical Monitoring
 Chemical monitoring uses heat-sensitive
chemicals (rather than live spores as in
biological monitoring).
 It involves the use of indicators that change
color or physical form when exposed to high
temperatures or to certain combinations of
time, temperature, and the presence of
steam.
46

Mechanical Monitoring
 Mechanical monitoring of the sterilization
process involves observation of the gauges
and displays on the sterilizer and recording of
the sterilizing temperature, pressure, and
exposure time
47

Biological Monitoring
 Evaluates the sterilization procedure’s
effectiveness
 Types of biological indicators (BIs)
 Use of biological indicators
 Analysis of biological indicators
 Management of biological monitoring
 What are biological indicators?
 They contain the bacterial endospores used for
monitoring.
48

Biological Monitoring (Cont.)
49

Biological Monitoring (Cont.)
50

Sterilization Failure
 If the biological monitoring fails to kill spores,
this event requires immediate action so as
not to compromise patient safety
 When a spore test is positive, it indicates a
sterilization failure
51

Sterilization Failure
 Table 13.4 discusses some causes of
sterilization failure.
 See Procedure 13.3 for steps to follow when
a spore test is positive.
52

 What questions should one ask to ensure the
correctness of the spore testing procedure?
 Were proper BIs used and stored properly?
 Did all of the BIs have the same manufacturer's lot
number?
 Were the BIs used before their expiration date?
 Were the BIs handled properly before and after
processing through the sterilizer?
 Were all the BIs mailed back to the service together or
analyzed in the office together?
 Were the BIs incubated for the correct time at the correct
temperature?
 Did the unprocessed control BI from the same lot number
show growth [yield a positive result] after culturing?
 If a mail-in service is used, did the service confirm the
positive result by microbiological means?
53

Chemical Monitoring
 Involves the use of heat-sensitive chemicals to
assess physical conditions during sterilization
process
 Two types of chemical indicators include:
 Indicators that change color after a certain temperature has
been reached
 Integrated indicators that change color or form slowly,
responding to a combination of time and temperature
 Procedure 13.4 summarizes the use of chemical
indicators.
 Autoclave tape is a chemical indicator that can
change color.
 An indicator that changes color or form slowly is
commonly put inside every pack, pouch, or cassette.
54

Chemical Indicators
55

Chemical Indicators (Cont.)
56

 Involves observation of the gauges and
displays on the sterilizer and recording of the
sterilizing temperature, pressure, and
exposure time
 Although correct readings do not guarantee
sterilization, incorrect readings can give the
first indication that a problem likely has
occurred
57

 Sterilizer gauges and displays indicate the
conditions in the sterilizer chamber rather
than conditions within the packs, pouches, or
cassettes being processed.
 Mechanical monitoring may not detect
problems resulting from overloading,
improper packaging material, or use of closed
containers.
 Mechanical monitoring alone will not detect
all potential problems that may cause
sterilization failure.
58

Mechanical Monitoring (Cont.)
59

Handling of Processed Instruments
 The proper handling or processed items is an
important part of the sterility assurance
program for the office
 Know the importance of every step involved
 Drying and cooling of instruments
 Storage of instruments
 Distribution of instruments
 Opening of instrument packages
60

Handling of Processed Instruments
 Keep handling of sterile packages to a
minimum.
 Prevent the mingling of sterile packs with
nonsterile packs.
 Examine each package carefully before
opening to ensure nothing happened during
storage.
 Instruments from sterile packs should be
placed on sterile trays at chairside.
61

Design of Instrument Processing Area
 The instrument processing area should be
located centrally, if possible, for easy access
from all operatories, but it should be away
from traffic flow
62

Design of Instrument Processing
Area
 If the instrument processing area is not located in a
room separate from the clinical area, then consider
the following:
 The instrument processing area should be as far away as
possible from the dental chairs.
 Use surface covers to protect the processing area when
not in use and when patients are being treated.
 Store sterile packages, trays, and cassettes in closed
cabinets or drawers.
 Do not process instruments or handle sterile packages
when patients are being treated.
63

Workflow Design
 Recommended designs include a U-shaped
workflow pattern in a room with a single door
 Key aspect in design of the processing area
is to separate the three main areas of activity
into the following:
 Decontamination area
 Packaging area
 Sterilizing and storage area
64

Workflow Design
 Usually a single room is involved and the separation
is by space designation, using signs rather than
walls or partitions.
 Proper placement of signs (e.g., “Contaminated
Items Only,” “Cleaned Items Only,” “Sterile Items
Only,” “Decontamination Area,” “Clean Packaging
Area,” “Sterilization Area”).
 See Table 13.6 for common equipment and supplies
used in the instrument processing facility.
65

Instrument Sharpening
 Difficult to manage from an infection control
point of view
 Presents a risk for disease spread through
accidental punctures
 The greatest safety is achieved by cleaning,
sterilizing, sharpening, and re-sterilizing
66

Instrument Sharpening
 If instruments (e.g., scalers) need to be
resharpened while being used on a patient, the
best (and safest) option is to provide several
scalers in each instrument setup rather than to
sharpen contaminated scalers.
 If one must sharpen instruments at chairside, one
should provide cleaned and sterilized sharpening
stones for each patient.
 When sharpening a contaminated instrument, one
should consider taping the sharpening stone to the
countertop and using one hand to sharpen the
instrument. 67

Instrument Protection
 Instrument processing can cause damage to
instruments
 Stainless steel instruments are the least
affected by corrosion, but many dentists
prefer carbon steel instruments because they
retain sharp edge longer
68

Handpiece Asepsis
 Clean, package, and sterilize the following by
heat processing between patients:
 High-speed handpieces
 Reusable prophylaxis angles
 Nose cones
 Slow-speed handpiece motors
69

 Procedure 13.5 presents guidelines for processing
handpieces.
 Decontamination procedures must address the
outside and the inside of handpieces.
 Flush the high-speed handpiece, air/water syringe,
and ultrasonic scalers for about 25 seconds at the
completion of each appointment.
 This helps flush out any foreign materials and brings
fresh water (and chlorine if city water) into the
system.
 Also, check the functioning of the antiretraction
valves at least every month.
 Wear personal protective equipment such as gloves,
mask, and protective eyewear or face shield and
protective clothing during these procedures. 70

Sterilization of Heat-Labile Items
 Although most reusable instruments can
withstand heat processing, a few plastic-type
items will be damaged by the heat, including:
 Some rubber dam frames
 Shade guides
 Rulers
 X-ray collimating devices
 Liquid sterilants can be used in these
circumstances
71

 Procedure 13.6 gives step-by-step
procedures for the use of a liquid sterilant.
 Use a liquid sterilant/high-level disinfectant
(e.g., 2.0% to 3.4% glutaraldehyde; a special
7.0% hydrogen peroxide) to sterilize these
items.
72

 Sterilization in a liquid sterilant/high-level
disinfectant requires an extended contact time that
ranges from 3 to 12 hours, depending on the
product (e.g., glutaraldehyde requires a 10-hour
contact time, and anything less than 10 hours is
disinfection, not sterilization).
 Use of a liquid sterilant/high-level disinfectant or
other liquid germicide to disinfect heat-tolerant
instruments is not recommended.
73

Other Methods of Sterilization
 Use of ethylene oxide gas
 Ethylene gas requires 4 to 12 hours, which is a
disadvantage.
 Vaporized hydrogen peroxide gas plasma
 Bead “sterilizers”
 Bead sterilizers are not a good means of sterilizing
instruments for reuse on another patient because
biological indicators are not available.
 Hot oil sterilizers
 See Boxes 13.3 and 13.4 for properties to
consider when selecting cleaners, sterilizers,
instrument cassettes, packing materials, and
spore testing services.
74

Chapter 13: Intrument Processing

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Chapter 13: Intrument Processing