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  • Sterilization in orthodontics1 /certified fixed orthodontic courses by Indian dental academy

    1. 1. STERILIZATION IN ORTHODONTICS INDIAN DENTAL ACADEMY Leader in continuing dental education 1
    2. 2. INTRODUCTION  Infectious diseases have scourged the world throughout history.  Even today, infectious diseases have been discovered at a rate of one disease per year over the past 22 years. 2
    3. 3.  As the old saying goes "Prevention is better 'than cure".  Such universal precautions must be both comprehensive, to prevent infection transmission in all clinical situations, and realistic, to allow convenient provision of dental treatment. 3
    4. 4. HISTORY  The belief that disease was a result of human wrong doings was common and did not change until the causes of disease and disease transmission were investigated.  Girolamo Fracastorius - Existence of tiny living particles that cause contagious disease being spread by direct contact with humans and animals and by indirect contact with objects. 4
    5. 5.  Antony Van Leeuwenhoek who is considered "Father of Microbiology“ studied the debris surrounding teeth and was the first to observe bacteria using a crudely built microscope.  Sammelweis in Vienna and Holmer in U.S.A. first recognised the importance of hand washing in preventing the spread of disease agents. 5
    6. 6. TERMINOLOGIES  ASEPSIS The absence of infection or infectious materials or agents. (Miller)  INFECTION Infection is the multiplication and survival of microorganisms on or in the body. An infection does not always indicate disease, but disease seldom results Without infection. (Miller).  INFECTION CONTROL Infection Control is the prevention of multiplication and survival of microorganisms on or in the body of living and non living objects. It is the sum total of all the measures taken to prevent subsequent infection 6
    7. 7. STERLIZATION  It is defined as the process by which an article, surface, or medium is freed of all microorganisms either in vegetative or spore state. (Panikar)  Denoting the use of physical or chemical agents to eliminate all viable microbes, including all bacteria, viruses and spores. (Jerry R. Mc Ghee)  Sterilization is the process designed to kill bacterial spores, therefore its intended use is to kill all microorganisms. (D.C.N.A. 1991) 7
    8. 8. DISINFECTION:  Disinfection means the destruction of all pathogenic organisms or organisms capable of giving rise to infection. (Paniker)  Disinfection is a less lethal process intended to kill disease producing microorganisms but not bacterial spores (D. C. N. A - 199 1). 8
    9. 9. 9
    10. 10. 10
    11. 11. MICROORGANISM Hepatitis B (HBV) Hepatitis C (HCV) Hepatitis D (HDV) Herpes simplex type I DISEASE Hepatitis B Non -a non-B, hepatitis Delta hepatitis Oral herpes, Herpetic Whitlow ,Herpatic keratitis Herpes simplex type II Genital herpes HIV AIDS & ARC Neisseria gonorrhoeae Gonorrhoea Treponema pallidum Syphilis Pseudomonas aeruginosa Wound infections, abscesses Wound infection, abscesses Staphylococcus aures Clostridium Tetanus 11
    12. 12. Micro organisms transmitted by inhalation Micro organism Disease Varicella virus cytomegalovirus Measles (rubeola) Influenza virus Rubella virus Chicken pox Infections in infants Measles and mumps Myobacterium tuberculosis Influenza and common cold German measles Tuberculosis Sterptococcus pyogens Oral abscesses, rheumatic fever & endocarditis Candida albicans candidosis 12
    13. 13. Transmission of Infection Infection transmission during dental procedures is dependent on four factors:  Source of infection  Means of transmission  Route of transmission  Susceptible host 13
    14. 14. SOURCE OF INFECTION SOURCE Patient suffering from acute infections Patients in Prodromal stage of infection carriers Known carrier Unknown carrier 14
    15. 15. How dental staff acquires infections Injuries caused by contaminated instruments  Injuries caused by contaminated instruments may create a portal of entry for pathogenic micro-organisms. If the number of micro-organisms introduced by this route exceeds the infective dose, infection may result. 15
    16. 16. Risk of infection following needle stick injury  The estimated blood on a needle stick is about 1.4µL and the amount required to cause an hepatitis or HIV infection is about 0.1µL and the incidence of infection is about 20 -25%after needle stick injury. 16
    17. 17. Existing lesions on the operator's hands  The incidence of HBV infection among the dental profession is about five times higher than in the general population.  Members of the orthodontist’s team who operate ungloved are at risk. 17
    18. 18. Dental aerosol  Aerosol is defined as small droplets, usually 5 µ or less in diameter, which can remain suspended in air for some time.  Mycobacterium tuberculosis has been detected in dental aerosols and there is an increased incidence of tuberculosis in dental professionals. 18
    19. 19. Splashes of contaminated sharp material  When operating the turbine hand piece, particles over 0. 1 mm in diameter are dispersed up to 6 meters at speeds of 50-60 km.  It has been suggested that hepatitis B and herpes simplex type I can be transmitted by these means 19
    20. 20. How does the patient acquire infection  Lesion on the operators ungloved hands  Contaminated gloves or hands  Contaminated instruments and other dental equipment. 20
    21. 21. Manifestation in dental health care workers HERPETIC WHITLOW (due to ungloved hands) HERPETIC KERATITIS(caused by contaminated aerosols) 21
    22. 22. CATEGORIZATION OF INSTRUMENTS  Critical instruments  If an instrument will be used to penetrate tissue or to touch bone it must be sterilised. 22
    23. 23. Semi-critical instruments  Semi-critical instruments: mirror, probe, and tweezers.  If an instrument will touch mucous membranes, but will not be used to penetrate tissue or to touch bone,it should be sterilised. 23
    24. 24. Non-critical instruments  These are defined as equipment and surfaces which contact only intact skin, such as mixing slabs and spatulas. 24
    25. 25. Hand Washing  To destroy pathogenic micro-organisms which collect on the hands  To prevent blood which contains pathogenic micro-organisms 25
    26. 26. Mechanical removal of debris and of transient micro-organisms  Rubbing removes micro-organisms from the skin.  Lathering holds them suspended away from the skin's surface.  Rinsing washes them off the hands. 26
    27. 27. Disinfection  The disinfectant action of hand washing will destroy in situ micro-organisms on the surface of the hands. 27
    28. 28. Hand scrubs and hand washes Properties  Act fast  Not irritate the skin after repeated use  Have a broad range of bactericidal and residual activity. 28
    29. 29. Antiseptics used in hand washing Chlorhexidine  This is 2-4% chlorhexidine gluconate with 4% isopropyl alcohol in a detergent solution with a pH of 5.0 to 6.5.  More effective than povidone iodine POVIDONE IODINE  These products contain 7.5% to 10% povidone iodine providing 0.75% to 1.00% available iodine. 29
    30. 30. Phenolic compounds  Hexachlorophene  Can be absorbed into the blood stream through intact skin, although it is more readily absorbed through abraded skin. It may be toxic if the blood concentration rises with repeated exposure.  Parachlorometexylenol (PCMX) is bactericidal and fungicidal at 2% concentration. It is not toxic. 30
    31. 31. ALCOHOLS  Ethyl alcohol and isopropyl alcohol are widely used as topical skin antiseptics, and have a potent bactericidal effect, especially at 70% concentration. 31
    33. 33. 33
    34. 34. Elbow taps should be used and clean tissue should be used for wiping 34
    35. 35. Personal hygiene  Facial hair should be covered with a face mask  Hair should be short or kept away from the face.  Jewellery should not be worn on the hands or arms during clinical sessions.  Nails must be kept clean and short. 35
    36. 36. Personal Protection  Barriers considered essential when performing all dental procedures are:  Gloves  Masks  Protective eyewear 36
    37. 37. Gloves The main types of gloves used in dentistry are:  Latex gloves: non-sterile and sterile  Vinyl gloves: non-sterile and sterile 37
    38. 38. Latex gloves  To protect patients from becoming infected with micro organisms on the operator's hands.  To protect the operator and staff from microorganisms present in the patient's blood and saliva 38
    39. 39. Non-sterile latex gloves  Examinations  Routine restorative procedures  Prosthetic and endodontic treatment  Prophylaxis Radiography Laboratory work. 39
    40. 40. Single use versus re-use Repeated use of one pair of gloves with disinfection between patients is not advisable for the following reasons 40
    41. 41. Double gloving  Double gloving reduces the risk of puncture.  The enhanced safety has to be balanced against the discomfort or reduced dexterity. 41
    42. 42. 42
    43. 43. 43
    44. 44. 44
    45. 45. Orthodontist's gloves  The risk of glove puncture is high for orthodontists, who repeatedly handle wire bands and ligatures.  Orthodontist can use puncture resistant gloves which are thicker at the palm, a high stress area for ligature placement and thinner material at the finger tips. 45
    46. 46. Masks  Aerosols and splatter  Aerosols are generated by turbine handpieces, air/water syringes, and ultrasonic scalers.  Droplets of blood are also splattered over the face during dental procedures, and these may contact existing skin lesions or skin damaged by sharp, flying debris. 46
    47. 47. Properties of an ideal mouth mask  It has a bacterial filtration efficiency of 95% or more  It does not contact nostrils or lips  It has both high filtration of small particles  Close fit around the entire periphery  It does not cause fogging of the eye glasses 47
    48. 48. The nose piece of the fluid shield mask 48
    49. 49. Eye Protection Causes of eye damage  Sharp particles projected at speed from the mouth when using the turbine hand piece, ultrasonic scaler, and air/water syringe may cause eye injury  Blood/saliva droplets may enter the operator's eyes and may transmit infection. 49
    50. 50. Protective glasses with side pieces A chin length face shield which protects the whole face Disposable with a plastic face shield 50
    51. 51. LIMITING CONTAMINATED AEROSOLS AND SPLATTER  Pre treatment brushing and use of a pre treatment mouth wash  High velocity aspiration  The use of rubber dam  Efficient air filtration and ventilation 51
    52. 52. 52
    53. 53. Protective clothing  To protect street clothes from contamination, wear a uniform or cover with a gown or coat.  Contaminated clothes should be washed at 80ºC for 10 mins using a strong detergent and bleach if possible Sleeves  Long-sleeved uniforms are recommended. Tuck the bottoms of the sleeves into the gloves 53
    54. 54. Tuck bottom of sleeves into the gloves 54
    55. 55. Footwear  A pair of smooth, slip-on shoes should be kept exclusively for use in the surgery. These should be cleaned at the end of each clinical session. Head covers  Head covers provide an effective barrier. 55
    56. 56. Covering surfaces Surfaces can be covered with  Clear plastic wrap  Aluminium foil  Paper with impervious backing  Commercially available ,polythene sheets and tubing 56
    57. 57. 57
    58. 58. Surface disinfection in case covering is not used 58
    59. 59. Recommended surface disinfectants PRODUCT DILUTION RECOMMENDE D TIME SODIUM HYPOCHLORIT E5.25% (BLEACH) 1:10 10 mins IODOPHORS Biocide Surf-a-cide 1:213 10 mins COMBINATION SYNTHETICS Phenolics Multicide Omni II Vitaphine 1:32 10 mins 59
    60. 60.  All these materials have the disadvantage of leaving surfaces wet for 10 minutes, which is inconvenient in a busy dental practice.  Glutaraldehyde products that are intended to be used as surface disinfectants contain only 0.25% (w/v) glutaraldehyde. 60
    61. 61. Disinfection of small surfaces between patients  Preclean, using the spray-wipe technique, with a recommended pre cleaning solution or water and detergent.  Spray with a product containing 70% alcohol, plus a low concentration of synthetic phenolic. Leave this solution on the surface for 3 minutes. 61
    62. 62. Spillages  Cover the spillage with Virkon powder or Presept granules and leave for 3 minutes  Remove the residue using strong paper towels soaked in disinfectant (sodium hypochlorite or Virkon) and place these in a disposal bag. 62
    63. 63. Disposables  If an instrument or item cannot be satisfactorily sterilized or disinfected, then choose a disposable alternative.  If an instrument or item can be appropriately sterilized or disinfected quickly, efficiently, and with minimal damage, do, not use the disposable alternative unless it is very cheap and of similar quality. 63
    64. 64.  Anaesthetic needles and cartridges  Mouthwash Cups/beakers  Saliva ejector tips  Intra-oral radiograph holders  The patient's protective bib  Surgical masks  Operating gloves  Disposable impression trays  Prophylactic Polishing cups and brushes 64
    65. 65. VARIOUS TYPES OF DISINFECTANTS AND THEIR USES CHEMICAL USED APPLICATION Chlorine compounds Surface disinfection Iodophors Surface disinfection Combination synthetic phenolics Surface disinfection & immersion disinfectant 2%glutaraldehyde Surface disinfectant & high level immersion disinfectant 65
    66. 66. Instrument Arrangement and Packaging 66
    67. 67. The advantages of using trays  Allows instruments to be set up in an organised way.  Restrict gross contamination to a surface which can be cleaned and sterilised  Provide safe, aseptic storage (pouches and paper wraps may be penetrated by sharp instruments).  Trays are particularly useful for sets of larger instruments. 67
    68. 68. Sterilisation Pouches  Pouches are very useful for the sterilisation and aseptic storage of single instruments  Each pouch should be flatted by hand, to drive out most of the air, and must contain a chemical time/temperature indicator strip. 68
    69. 69. Clear view pouches with TST strips 69
    70. 70. Sterilisation of Instruments  There are four distinct stages which achieve safe instrument sterilisation:  Pre-cleaning disinfection, using 'holding' solutions.  Pre-sterilisation cleaning.  Sterilisation.  Aseptic storage. 70
    72. 72. Pre-Sterilisation Disinfection  After use, Place instruments into a disinfectant detergent solution in a container located within the operating zone near to the dentist.  At the end of the dental procedure, take the container to the sterilisation area. Thoroughly rinse the instruments with water. The solution should be discarded daily.  A synthetic phenolic solution diluted 1:32, is an ideal holding solution 72
    73. 73. PRE STERILISATION CLEANING  Proteinaceous material protects microorganisms on the surface of instruments from heat and other sterilisation conditions. Pre-sterilisation cleaning may be achieved in one of three ways:  Hand scrubbing  Ultrasonic cleaning  Dishwasher instrument cleaning. 73
    74. 74. 74
    75. 75. Sterilisation  Instruments must be clean and dry before sterilisation. There are four types of sterilisers used routinely :  The steam autoclave.  The chemical vapour pressure steriliser.  The dry heat oven.  The glass bead/salt steriliser. 75
    76. 76. THE STEAM AUTOCLAVE  A steam autoclave sterilises by the use of steam under pressure. Non-vacuum autoclaves are used in dental practice.  A prescribed temperature, pressure, and time are necessary to destroy bacterial spores. The faster, higher temperature cycles are generally favored by dentists in general practice. 76
    77. 77. Chemical vapour sterilisers  Chemical vapour sterilisers operate by heating a deodorized alcohol, formaldehyde, and ethyl methyl ketone solution, which can be obtained from the manufacturer, to 132ºC at 138-276 kPa (20-40 lb/in2) for 20 minutes in a closed chamber. 77
    78. 78. Instruments suitable for sterilisation with chemical vapour  All dental hand instruments.  Orthodontic wires and bands.  Orthodontic pliers 78
    79. 79. Dry-heat sterilisers  Convection heat has become a popular means of sterilisation of instruments for orthodontic offices.  Dry heat is an effective means of sterilisation, when it is used properly. Unwrapped, moderate loads of instruments placed in an oven can be sterilised at 160-170ºC in I hour. 79
    80. 80. HOT AIR OVEN 80
    81. 81. GLASS BEAD STERILIZER  To have an effective sterilization one has to have many sets of instruments where single use is possible after sterilizing them in a hot air oven, or one has to wait for long enough to have effectively sterilized in between appointments.  So there is acute necessity in the orthodontic office set up, where instruments can be sterilized quickly and rapidly. 81
    82. 82. Conventional Customized glass bead glass bead sterilizer sterilizer for orthodontic instruments 82
    83. 83. Disinfection of impressions  The most commonly used impression material is alginate and these impressions are highly infected when removed from the patients mouth 83
    84. 84. Recommended Procedure for disinfecting the alginate impression  Rinse the impression thoroughly under running tap water, shake the impression to remove excess water.  Dip the impression in a 1:10 solution of sodium hypochlorite for several seconds to ensure maximum contact of undercut with the disinfectant. 84
    85. 85.  Wrap the impression in gauze soaked in 1:10 sodium hypochlorite, place in a plastic bag and seal for 10 minutes.  Remove the impression and rinse thoroughly under running tap water. 85
    86. 86. Visible-light curing units  Some new designs of unit feature removable, autoclavable light curing tips. However, the handles still present a problem, since they cannot be sterilised. 86
    87. 87.  Units: Should be cleaned and disinfected with a phenolic disinfectant after use.  Plastic units should be disinfected using an iodophor.  Glutaraldehyde disinfectants have been found to damage the glass rods in a fiberoptic light tip, with a subsequent reduction in light output; the use of this disinfectant should be avoided. 87
    88. 88. Monitoring sterilisation  Tests using chemical indicators  Test strips or tubes are available for autoclaves, chemiclaves, and dry-heat ovens  Several types of colour-change strips or tapes indicate temperature change only, that is, they only show that the load has been in a heat steriliser. 88
    89. 89. Biological Monitors  Bacillus stearothermophilus is used for chemical vapour and steam sterilisers, and B. subtilis is used for dry-heat spore testing. 89
    90. 90. Disposal Clinical Waste  Used disposable scalpels, anaesthetic cartridges, used burs, orthodontic wire, extracted teeth, and other sharp objects should be carefully dropped into a solid puncture-resistant container 90
    91. 91. 91
    92. 92. CATEGORY OF WASTE CONTAINER CAT I Blood body fluids bandages, microbiology,& biotechnology waste, extremely soiled lining Tubes ,buckets Yellow with lids CAT 2 Sharps Reusable sharps such as needles scalpels surgical instruments Waste sharps such as broken glass disposable needles broken blades Stainless steel White or translucent Card board boxes Blue CAT 3 Disposable plastics gloves Bgs or buckets stain less steel drums Red CAT 4 Chemical waste Buckets with Black lids ,card board cartons CAT 5 Compostable waste Buckets and drums COLOUR Green 92
    93. 93. SUMMARY  In every health profession the guiding principle is “DO GOOD BUT DO NO HARM” is as HARM applicable today as it was in the time of Hippocrate.  Sterilization in orthodontic office is an important exercise, due to unabated spreading of HIV virus, hepatitis viruses, there is a great concern regarding the sterility of orthodontic instruments. 93
    94. 94. WHICH IS THE IDEAL METHOD ?  The ideal method for sterilization should be economical , less time consuming ,with low maintenance cost , require minimum space and infrastructure and the method which complies by all these requirements is a GLASS BEAD STERILIIZER 94
    95. 95. 95