Immunity and infection control /orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTS
 Introduction
 Immunity
 Antigen
 Antibody
 Complement system
 Antigen – Antibody Reactions
 Hypersensitivity
 Autoimmunity
 Immunodeficiency
 Micro-organisms of relevance in dentistry
 Nosocomial Infection
 Cross infection
 Infection control
 Hospital waste disposal
 Conclusion
 List of references www.indiandentalacademy.com

INTRODUCTION

Immunity:
Latin word ‘Immunis’- exempt
Resistance exhibited by the host towards any injury caused
by micro-organisms & their products.
HISTORY :
15th
century – Chinese & Turks – Variolation
1798 - Edward Jenner – cowpox pustules in
smallpox patients
1881 - Louis Pasteur coined ‘vaccine’
1883 - Metchnikoff - phagocytes - ingest
microorganisms

1885 – Pasteur administered 1st
vaccine
1901 - Emil vonBehring – serum from immunised animals
transfer immunity
1930 – Elvin Kabat – gammaglobulins – immunity
1950 – Lymphocytes – cellular & humoral immunity

Classification

INNATE IMMUNITY:
NON-SPECIFIC DEFENCE:
1. Mechanical barriers
2. Physicochemical barriers
3. Antibacterial substances
4. Elimination of infections agents through urine &
bronchial secretions
SPECIFIC DEFENCE:
1. Specificity for a particular antigen
2. Memory

ACQUIRED IMMUNITY:
 Active immunity: resistance developed as a result of
antigenic stimulus
 Natural Active immunity : Microbes
eg : measles , chicken pox
 Artificial Active immunity : Vaccines
eg : BCG
 Natural Passive immunity : Mother to child
eg : IgA in Colostrum
 Artificial Passive immunity : Antibodies
eg : Anti tetanus serum

IMMUNE SYSTEM :Lympho-reticular system
Lymphoid cells Lymphoid organs
Lymphocytes Primary: Thymus, bone marrow
Plasma cells Peripheral: Lymph node, spleen
• Antibody mediated / Humoral Immunity : Plasma cells
• Cell mediated / Cellular Immunity : Lymphocytes
• Specific Immunity : Lymphocytes , Plasma cells
• Non Specific immunity : Phagocytic cells

SURFACE MARKERS:
CD number Cell type association
CD 1 Thymocytes , langerhans cells
CD 2 T-cells
CD 3 T-cell antigen receptor complex
CD 4 Helper T-cells
CD 8 Suppressor or Cytotoxic T -cells
CD 19 B -cells
NULL CELLS: surface markers absent
eg – NK cells , Antibody dependent cellular
cytotoxic lymphocytes

ANTIGEN:
Any substance which when introduced into the body, stimulates
the production of an antibody with which it reacts
specifically and in an observable manner.
eg: cells, proteins, polysaccharides
Attributes of Antigenicity:
1. Immunogenicity
2. Immunological reactivity
Types:
1. Complete antigen
2. Hapten

ANTIBODY :
Proteins that appear in circulation after infection or immunization
and have the ability to react specifically with the antigen
Also called gamma globulins.
STRUCTURE : Porter and Edelman

PROPERTIES :

FUNCTIONS :
Ig G – protects body fluids
Ig M – protects blood stream
Ig A – protects body surfaces
Ig D – recognizes antigens on the surface of B lmphocytes
Ig E – mediates reagenic hypersensitivity
ANTIGEN – ANTIBODY REACTION :
Antigen and antibody combine with each other in a specific and
observable manner
• In vitro – Serological reactions
• In vivo – Hypersensitivity reactions

CLASSIFICATION :
Morphologically,
1. Precipitation reaction : soluble antigen + antibody
2. Agglutination reaction : insoluble antigen + antibody
Functionally,
1. Neutralization
2. Complement fixation
3. Opsonization
4. Immunofluoresence
5. Enzyme immunoassay

COMPLEMENT SYSTEM :
Complement : Factors which occur in the normal serum & are
activated characteristically by antigen – antibody interaction
and subsequently mediate a number of biologically significant
reactions which form the complement system
Ehrlich – complement
Ig M and Ig G – fix the complement
COMPLEMENT ACTIVATION :
• Classical Pathway
• Alternate or Properdin Pathway

IMMUNE RESPONSE :

HYPERSENSITIVITY :
Abnormal state of immune reactivity that has deleterious
effect on the host
CLASSIFICATION:
I. Depending on the time elapsed between exposure and
appearance of symptoms :
• Immediate
• Delayed
II. Gel & Coombs Classification :
• Type I – Immediate
• Type II – Cytotoxic
• Type III – Immune complex
• Type IV – Delayed

AUTOIMMUNITY :
A condition in which a structural or functional damage
is produced by the action of immunologically competent cells
or antibodies against normal components of the body.
eg : Rheumatoid arthritis, Sjogren’s syndrome, SLE
MECHANISM :
1. Release of hidden or sequestered antigen into the
circulation.
2. Antigenic alteration in cells or tissues due to physical,
chemical or biological influences
3. Defects of T and B cells
4. Increase in helper T cells & decrease in cytotoxic T cells

IMMUNODEFICIENCY :
Immunodeficiency diseases are the conditions where
the defence mechanisms of the body are impaired ,
leading to repeated microbial infection of varying
severity and sometimes enhanced susceptibility to
malignancies
CLASSIFICATION :
I. Primary
II. Secondary

PRIMARY IMMUNODEFICIENCY INCLUDES
1. DISORDERS OF SPECIFIC IMMUNITY
A. B-cell defects
B. T-cell defects
C. Combined immunodeficiencies (T and B cells)
2. DISORDERS OF COMPLEMENT
A. Complement component deficiencies
B. Complement inhibitor deficiencies
3. DISORDERS OF PHAGOCYTOSIS
A. Chronic granulomatous disease
B. Chediak Higashi syndrome
C. Leucocyte G6PD deficiency
D. Lazy leucocyte syndromewww.indiandentalacademy.com

SECONDARY IMMUNODEFICIENCES
1. Malnutrition – Protein Energy Malnutrition, Vitamin D
deficiency
2. Systemic disorders – Hypogammaglobulinemia, renal
insufficiency, extensive burns, uncontrolled diabetes
3. Drug induced – cytotoxic drugs, corticosteroids,
antimicrobial drugs, captopril, silver salts, phenytoin
4. Surgery
5. Malignancy – B-cell malignancy, Non-Hodgkin’s
lymphoma
6. Infectious diseases – HIV, EBV

MICRO-ORGANISMS OF RELEVANCE IN DENTISTRY
1. BACTERIA
a. Gram positive – Streptococcus, Staphylococcus,
Corynebacterium, Lactobacilli, Actinomyces, Clostridium
b. Gram negative – Hemophilus, Salmonella, Actinobacillus,
Bacteroides, Porphyromonas, Fusobacterium
c. Spirochetes – Treponema
d. Mycobacterium
2. VIRUSES
a. DNA viruses – HPV, Herpes virus
b. RNA viruses – Hepatitis B, HIV, Measles, Mumps
3. FUNGI – Candida, Cryptococcus neoformans

1. Streptococcus pyogenes (group A) –
a. tonsillitis,
b. pharyngitis,
c. scarlet fever,
d. sinusitis,
e. wound infection leading to cellulitis and lymphangitis
f. Rheumatic fever
Streptococcus viridans –
a. Plaque
b. Caries
c. Infective endocarditis
Infections caused by gram positive organisms

2. Staphylococci –
a. Superficial infections (boil, carbuncle, pustule, abscess,
conjunctivitis)
b. Deep infections (osteomyelitis, endocarditis, septicemia)
c. Toxic Shock Syndrome
2. Corynebacterium diphtheriae –
a. Diphtheria
2. Lactobacilli –
a. deep carious lesions
Infections caused by gram positive organisms – cont.

5. Actinomyces –
a. Actinomycosis
6. Clostridium –
a. Clostridium tetani (tetanus),
b. Clostridium perfringens (Gas gangrene, food
poisoning)
Infections caused by gram positive organisms – cont.

1. E. coli and Salmonella –
a. septicemia
b. osteomyelitis
2. Hemophilus -
a. osteomyelitis,
b. acute epiglossitis
3. Actinobacillus –
a. LJP,
b. rapidly destructive adult periodontitis
Infections caused by gram negative organisms

4. Capnocytophaga –
a. periodontal pockets
4. Fusobacterium –
a. ANUG,
b. Vincent`s angina,
c. Cancrum oris (Noma)
4. Bacteroides and Porphyromonas –
a. Periodontitis
Infections caused by gram negative organisms – cont.

1. Mycobacterium –
a. TB
b. Leprosy
2. Treponema –
a. Syphilis
b. ANUG
Infections caused by mycobacterium and spirochetes

Infections caused by Herpes virus
• Herpes simplex
a. HSV 1 – primary gingivostomatitis, Herpetic Whitlow,
Conjunctivitis, Keratitis, Encephalitis.
b. HSV 2 – genital lesions
• Varicella Zoster
a. Chicken pox
b. Herpes zoster – reactivation of virus in the dorsal root
or trigeminal ganglion
c. Ramsay Hunt syndrome – herpes zoster with rash on
tympanic membrane and external auditory canal with
unilateral facial nerve palsy

• Cytomegalovirus (CMV)
a. Infection of salivary gland
• Ebstein barr virus
a. Infectious mononucleosis
b. Burkitt’s lymphoma
c. Nasopharyngeal carcinoma
d. Hairy leucoplakia
Infections caused by Herpes virus – cont.
• Human herpes virus
a. HHV8 - Kaposi’s sarcoma in AIDS

HEPATITIS B (SERUM HEPATITIS)
• DNA virus
• Transmitted through parentral route, saliva
• Incubation period = 1 – 6 months
• Hepatitis B and dentistry
• Dentists are highly prone
• HBV present in increased concentration in gingival
sulcus as a result of continuous serum exudate
• Also present in mixed saliva

Infections caused by RNA viruses
• Paramyxovirus
a. Mumps – parotitis
b. Measles – acute febrile illness +
exanthematous rash
• Coxsackie virus – Herpangina
• Hepatitis A virus – infectious hepatitis
• HIV – AIDS

AIDS (Acquired Immunodeficiency Syndrome) -
• First reported in USA in 1981
• Caused by HIV
• Modes of transmission
1. Sexual contact
2. Sharing of needles and syringes among IV drug
users
3. Mother to child (transplacental, perinatal, breast
feeding)
4. Blood transfusion
5. Transplantation of infected organs

HIV and immune system –
• Primary targets are CD4 cells particularly Helper
T-cells
• Specific binding of virus to CD4 by envelope
glycoprotein gp120
HIV infection is divided into –
1. Group I – acute infection
2. Group II – asymptomatic infection
3. Group III – persistent generalized
lymphadenopathy
4. Group IV – ARC (AIDS related complex)www.indiandentalacademy.com

Oral manifestation of HIV infection
• Group I – lesions strongly associated with HIV
• Candidiasis, hairy leucoplakia, NUG, NUP, Kaposi’s
sarcoma
• Group II – lesions less commonly associated with HIV
• Mycobacterium avium intracellulare, necrotizing
stomatitis, ulcerations, xerostomia,
thrombocytopenic purpura, HSV, HPV, Herpes zoster

Group III – lesions seen in HIV
• Bacterial – actinomycosis, K. pneumoniae
• Fungal – cryptococcus, histoplasma
• Viral – CMV
• Parasitic - pneumocystitis carnii
• Drug reactions – Lichenoid reactions, recurrent
aphthous stomatitis
MANAGEMENT –
1. Surveillance
2. Antibiotics
3. Isolation

FUNGAL INFECTIONS
Candidiasis : most common
• Causes mucosal, cutaneous and mucocutaneous lesions
• Seen in –
• old age,
• immunocompromised patients,
• patients on heavy antibiotics,
• oral contraceptives,
• ill fitting dentures,
• malignancy,
• radiation,
• heavy smoking. www.indiandentalacademy.com

INFECTION :
Invasion and multiplication of micro-organisms in body tissues
causing local cellular injury due to competitive metabolism,
toxins, intracellular replication or antigen-antibody reaction.
CROSS INFECTION :
It is the spread of micro-organisms from one person to another
and takes place by the following pathways –
1. Patient to dental personnel
2. Dental personnel to patient
3. Patient to patient

ROUTES OF CROSS CONTAMINATION :
• Direct contact
• Droplet infection
• Indirect contact
In dentistry cross infection occurs through :
• Needle sticks & instrument puncture
• Invisible breaks or cuts in the skin
• Mucous membrane of the mouth , nose , eyes
• Through open lesions
• Inhalation

HOSPITAL ACQUIRED INFECTIONS (Nosocomial
infections) :
Infections developing in hospitalized patients, not present
at the time of their admission.
Causes :
•Exogenous – hospital ecosystem
•Iatrogenic – invasive diagnostic or therapeutic
procedures
•Opportunistic micro-organisms

MICROBIOLOGY :
• Staphylococcus aureus, S.epidermidis,
Gp D Streptococci
• Gram –ve bacilli - E.coli , Klebsiella , Pseudomonas
• Viruses - HIV , CMV , HSV ,Hepatitis B
• Fungi – Candida , Aspergillus
COMMON INFECTIONS :
• Wound infections
• UTI infections
• Respiratory infections
• Bacteremia & Septicemia

INFECTION CONTROL PROCEDURES
Infection control procedures can be described under
two headings :
1. Personal protection measures
2. Patient protection measures
PERSONAL PROTECTION MEASURES :
Prevention of cross infection from patient to dental
personnels & involves :
1. Personal hygiene
2. Clinic clothing
3. Barrier protection (gloves , eye shields ,face masks)

Personal hygiene :
1. Refrain from touching anything not required for the
procedure
2. Cover cuts and bruises on fingers
3. Hair should be tied up properly
4. Hands washed before & after treatment
Clinic clothing :
1. Changed daily
2. Aprons worn to protect the clothing
3. Aprons washed thoroughly and bleached

Gloves :
ADA & CDC recommend use of gloves
Types :
1. Clean , high quality ,protective latex gloves
2. Sterile gloves
3. Heavy duty utility gloves
Materials used :
1. Latex
2. Vinyl

Eye shields :
Protect the eyes from
• spatter and debris
• conjunctivitis
• Eye wear cleaned regularly
• Eye wear with side protection preferred
Face masks :
Prevent inhalation of contaminated aerosols
Filtration efficacy depends on :
• Materials used (paper mask < glassfibre /
polypropylene)
• Duration (30 – 60 min )

Rubber dam isolation :
• Minimizes saliva & blood contaminated aerosol
production
• Provides clear visual field
• Minimizes instrument contact with the mucosa
(minimizing tissue injury & subsequent bleeding)
PATIENT PROTECTION MEASURES
• Disinfection
• Sterilization

• Asepsis is freedom from pathogens
• Antisepsis is the procedure which inhibits or destroys
microbes on living tissues
• Sterilization is the process by which an article,
surface or medium is freed of all microorganisms either
in the vegetative or spore state.
• Disinfection is the process by which pathogenic
organisms are removed from the surface or an object.
This does not include bacterial endospores.

• Disinfectants used in dentistry :
1. Alcohols
2. Iodine products
3. Synthetic phenols
4. Aldehydes
5. Chlorine products

ALCOHOLS:
• Traditionally used in dentistry as a disinfectant.
• Isopropyl alcohol - most commonly used alcohol
- 60-70% in water.
• Mechanism - Denatures bacterial protein.
- bactericidal , virucidal ,not sporicidal
Advantages :
1. Economical
Disadvantages:
1. Ineffective in the presence of saliva or blood.
2. Rapid evaporation limits activity.
3. Damage rubber , plastic items

ALDEHYDES:
• Formaldehyde:
• Mechanism : Acts on amino group of bacterial protein
- bactericidal ,virucidal ,sporicidal
• 10% formalin + sodium tetra borate is used to disinfect
cleaned metal instruments.
• Formaldehyde gas - heat sensitive instruments
- fumigation of wards , laboratories
• Disadvantages : Formaldehyde gas is irritant and toxic
when inhaled.www.indiandentalacademy.com

• Gluteraldehyde : 2 % gluteraldehyde for less than
20 min – disinfectant
• Mechanism : - acts on bacterial proteins
- bactericidal , virucidal ,sporicidal ( if
used for 6 – 10 hours )
• Advantages : - used with rubber and plastic items
- less toxic , non corrosive
• Disadvantages : - allergenic
- severe tissue irritation
- may discolour some metals

IODOPHORES:
• Iodophores are compounds of iodine with nonionic wetting
or surface active agents. eg: Povidone iodine [Betadine]
• Mechanism : - act on bacterial protein
- bactericidal , virucidal
• Advantages : economical
safe
• Disadvantages : - may discolour surfaces
- unstable at high temperatureswww.indiandentalacademy.com

CHLORINE :
• Mechanism : cell wall damage, enzyme system
blockage, protoplasmic poisoning.
• Effective against a wide spectrum of bacteria and
viruses.
• Advantages : - rapid action
- economical
• Disadvantages: unstable
corrodes metal and softens plastic
irritant to eye and skin.

PHENOL :
• Mechanism : Causes cell membrane damage and
cell lysis.
• Synthetic derivatives like lysols and cresols are active
against wide range of organisms.
• Effectiveness of phenolic compounds depends on contact
with bacterial cell.
• Advantages : economical
less toxic
used on metals , rubber , plastics
• Disadvantages : not sporicidal
irritant to eyes , skin

SURFACE ACTIVE AGENTS:
• They reduce surface tension.
• Cationic surface acting agents -
Quarternary ammonium compounds
• Mechanism : - act on phosphate group of cell
membrane
- bactericidal only
• Anionic surface acting agents – Soaps
• Mechanism : act on gram positive and gram negative
bacteria

Methods of

STERILIZATION can be divided into :
1. Presterilization cleaning
2. Packaging
3. Sterilization process
4. Aseptic storage
PRESTERILIZATION CLEANING :
1. Removal of contaminated instruments
2. Heavy duty utility gloves used
3. Sharps handled carefully
4. Scrubbing
manual
ultrasonic

PACKAGING :
• Protects cleaned instruments from
recontamination
• Instruments packaged using :
1. See - through sterilization bags
2. Self sealing paper / plastic pouches
3. Single layered cloth wrap

STERILISATION PROCESS :
• Physical agents:
1. Dry heat
2. Moist heat
3. Radiation
4. Ultrasonic and sonic vibration
• Chemical agents:
• Gases
1. Ethylene oxide gas
• Aldehydes
1. Gluteraldehyde
2. Formaldehydewww.indiandentalacademy.com

In dentistry commonly used methods for sterilization are :
• Dry heat
1. Hot air oven
2. Rapid heat sterilizer
3. Glass bead sterilizer
• Moist heat
1. Autoclave
• Chemical
1. Unsaturated chemical vapor sterilization
2. Gluteraldehyde solution

HOT AIR OVEN:
• Dry heat denatures protein of microorganisms rendering them
nonviable.
• Temperature of 160o
C for 1-2 hours.
• Sterilization time begins only after the proper temperature of
160°C is reached and then this temperature must be maintained.
• Advantages:
1] no corrosion
2] Cost effective
3] Items are dry after cycle
• Disadvantages:
1] longer sterilization time
2] Cannot sterilize liquids
3] May damage plastic and rubber
items www.indiandentalacademy.com

RAPID HEAT STERILIZER:
• Uses controlled internal air flow system at 375°F.
• Sterilization claims of 6 minutes are made with
unwrapped instruments and 12 minutes for wrapped
instruments.
Advantages:
1] no corrosion
2] Short cycle
3] Items are dry after cycle

Disadvantages:
1] cannot sterilize liquids
2] May damage plastic and rubber items
GLASS BEAD STERILIZATION:
•Used for small instruments like burs ,trimmers etc.
•Temperature - 450o
C for 5-30 seconds

AUTOCLAVE:
• Moist heat denatures and coagulates protein of
microorganisms.
• Sterilization is due to latent heat of vaporization present in
moist heat.
• When steam condenses on contact with cooler surfaces, it
becomes water and gives latent heat to that surface.
• This principle is used in autoclave.

• Temperature - 121°C for 20 minutes at 15 pounds pressure.
• For practical considerations high pressure vacuum models
are operated at a temperature of 136°C for 5 minutes at 30
pounds pressure.
• Advantages:
1] good penetration
2] Time efficient
3] Sterilize water based liquids
• Disadvantages:
May damage plastic or rubber items

ETHYLENE OXIDE STERILIZATION:
•High penetrating ability.
•It acts by alkylating the amino, carboxyl, sulphydril groups
in protein molecules and reacts with RNA and DNA.
•Used to sterilize heat sensitive instruments.
•Disadvantages:
1.Slow procedure - 4 hours at 54o
C and 12 hours at
room temperature.
2.Costly

LIQUID STERILIZATION:
• 2-3.2% Gluteraldehyde solution can kill
microorganisms and spores in 6-10 hours at room
temperature.
• Used for plastic or other items which cannot survive
heat sterilization.
• Items precleaned and dried ; submerged in solution for
required time and thoroughly rinsed.
• Lower concentration or lesser time leads to disinfection

Sterilization : ADA recommendations
• Rubber items and saliva ejectors:
Best method - discard after each use.
Ethylene oxide sterilization , dry or moist heat sterilization
-ineffective
• Hand pieces:
Steam, dry heat, chemical vapour and ethylene oxide
sterilization are preferred
• Burs and Stones:
Dry heat , chemical vapour and ethylene oxide gas
sterilization preferred.
Polishing stones - chemical vapour and ethylene oxide gas

• Impression trays:
Aluminum trays – autoclave , chemical vapor
Chrome plated trays - all methods of sterilization can be
employed.
Plastic or acrylic trays - ethylene oxide or gluteraldehyde
sterilization.
• Stainless steel hand instruments:
Autoclave, dry heat, chemical vapour and ethylene oxide
sterilization.
• Gloves and gauze - autoclaved.

• Tongue blade, lip and cheek retractors - steam or
dry heat
• Matrix band, spatula, light cure tip - steam or
gluteraldehyde sterilization.
• Glass slab and dappendish - steam, dry heat or
chemiclave.
• Three way syringe – gluteraldehyde sterilization
or chemiclave

RECOMMENDATIONS FOR DISINFECTING IMPRESSION
MATERIALS
IMPRESSION
MATERIALS
DISINFECTANTS
GLUTARALDEHYDE IODOPHORS SODIUM
HYPOCHLORITE
ALGINATE No Yes Yes
POLYSULFIDE Yes Yes Yes
SILICONES Yes Yes Yes
POLYETHERS No Yes Yes
REVERSIBLE
HYDROCOLLOID
No Yes Yes
COMPOUND No Yes Yeswww.indiandentalacademy.com

PROSTHETIC
DEVICE
DISINFECTANTS
GLUTARALDEHYDE IODOPHORS SODIUM
HYPOCHLORITE
COMPLETE
DENTURES
No Yes Yes
REMOVABLE
PARTIAL
DENTURES
No Yes Yes/ No
FIXED
PROSTHESIS
Yes No Yes/ No
STONE CASTS No Yes Yes
WAX RIMS No Yes No
RECOMMENDATIONS FOR DISINFECTING PROSTHETIC DEVICES
AND APPLIANCES

WASTE DISPOSAL :
Biomedical waste: Any waste which is generated
during the diagnosis , treatment or immunization of
human beings or animals or in research activities
pertaining thereto or in the production or testing of
biologicals
CLASSIFICATION :
1. Infectious waste
2. Pathologic waste
3. Sharps
4. Pharmaceutical waste
5. Chemical waste
6. Radioactive waste

METHODS OF WASTE DISPOSAL
1. Incineration :high temperature
dry oxidation
waste that cannot be reused,
recycled
2. Chemical disinfection :liquid
wastes like blood
3. Microwave irradiation
4. Land disposal :open dumps
sanitary landfill
5. Inertization : waste + cement
+ lime

COLOUR
CODING
TYPE OF
CONTAINER
WASTE CATEGORY TREATMENT
OPTIONS
YELLOW Plastic bag Human anatomical
wastes, animal waste,
microbiology and bio -
technology wastes and
solid wastes
Incineration/deep
burial
RED Plastic
bag/disinfected
container
Microbiology and bio -
technology wastes and
solid wastes
Autoclaving/microwa
ve/chemical
treatment
BLUE/WHITE
TRANSLUCENT
Plastic
bag/puncture
proof container
Waste sharps and solid
wastes
Autoclaving/microwa
ve/chemical
treatment/shredding
BLACK Plastic bag Discarded medicines,
incineration ash and
chemicals used in
production of biologicals
Disposal in secured
landfill

COLOUR CODING AND TYPE OF CONTAINER FOR DISPOSAL
OF BIOMEDICAL WASTES

CONCLUSION

List of references :
1. Medical immunology – Gabriel Virella , 5th
ed
2. Immunology – Richard Goldsby , 5th
ed
3. Textbook of Microbiology – Ananthnarayan , 6th
ed
4. Disinfection , Sterilization & Prevention
- Block.S.S, 5th
ed
5. Essential Microbiology for dentistry
- Samaranayke ,2nd
ed
6. Park’s Textbook of Preventive & Social Medicine
- K. Park , 17th
ed
7. Dentistry International 2005, 24 – 27
8. DCNA 1992 April
9. JADA 1989

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