Infection control orthodontic office

Infection control in
orthodontic office

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Content
Infection
 Principles of infection transmission
 Principles of infection control
 Infection control in orthodontic office
 Sterilization & disinfection
 Studies on infection control in orthodontic
office



Infection


“Multiplication & survival of microorganisms on

or in the body”

Cross infection


“The passage of microorganisms from one
person to other”.


History of sterilization


Leeuwenhoek(17 century)



Described microbes(shape-cocci,bacilli,spiral)





Simple microscope

Father of bacteriology

Edward Jenner(1749-1823)


Modern method of vaccination-small pox



Originally vaccination-injection cowpox-prevent
smallpox


Tyndall
First-sterilization method
Fractional sterilization

Pasteur(1822-1895)
Father of microbiology
Introduced-techniques of sterilization
Steam sterilizer,hot air oven,autoclave
Pasteurization



Joseph listure(1827-1912)



Father of antiseptic surgery



Disease-invading organisms-germ theory of
disease



Diluted phenol-wound infection




Robert koch(late19-early20)



Staining bacterial smears



Pure culture technique



Koch's postulate


Infection control


“Governing or limiting of the spread of
infections via different channels, in a specific or
general environment”.


Goals


risk of cross contamination



To correct break in aseptic technique



To use universal precautions



To protect pt’s & personnel- Infection


Principles of Infection Transmission
1.

A Source Infection

2.

A Mode / Vehicle

3.

Root of transmission


Source of Infection
1. With Overt Infection


Droplets, Discharges from mouth / Portals

2. Prodromal Stage of Infection


Viral Infection – Measles, Mumps, Chicken Pox

3.Carriers
Convalescent / Asymptomatic  Hepatitis B

Universal Infection Control
Patient
Carrier ?????

Reservoir of Pathogens

Universal Precaution

Dentist

Patient
Microorganism
Blood

Respiratory

Oral



HIV



HBV



HSV-1,2



CMV



TB-bacilli



Streptococci & Staphylococci

Route of Transmission
Direct Contact

Indirect Contact

•Blood

•Contaminated instruments

•Oral fluids

•Operatory Equipments

•Other Secretions

•Aerosols


Aerosols


Influenza, Common cold, TB



High speed Instruments
> 100 µ  Spatter

< 100 µ - Common


Chain of Infection
Susceptible Host

Virulent Pathogen

Portal of Entry


Index Case

Other Patients

Dentist

Infection Control

Infection Control Protocol
1.

Pt Evaluation

2.

Personal Protection

3.

Sterilization & Disinfection

4.

Safe Disposal of Waste

5.

Lab Asepsis

Pt Evaluation


Medical History


Personal Protection
1.

Personal Hygiene

2.

Clinic Clothing

3.

Barrier Protection

4.

Immunization Procedures

Personal Hygiene


Scrubbing



Touching



Cover – Cuts & Bruises



Washing – Hands



Finger nails

2.Clinic Clothing
•Uniform
•Daily change
•Washing
•OSHA-clinic premises

Barrier Protection
1.

Gloves

2.

Eye Shields

3.

Face mask

4.

Rubber dam isolations

Gloves


Disposable – new pair



Latex / Vinyl



Change – Long Procedures



After removal – washing hands


Eye Shields


Dentists – Support Personnel



Spatter – Debris



High speed Instrumentation



OSHA-fitted-solid side shields


Face Mask


High speed instrumentation



Aerosol – inhalation  RTI



Life – 30 to 60 minutes


Vaccines for Dentists


CDC & OSHA

Recommendation

Vaccines
• HBV,
•Influenza,
•rubella

•Measles

Sterilization & disinfection




Sterilization
“The process by which an article
surface or medium is freed of all
microorganisms either in vegetative or in spore
state”.



Disinfection
“Destruction of all pathogenic organisms
capable of giving rise to infection”.



Antisepsis
“Indicate the prevention of infection ,usually
by inhibiting the growth of bacteria”.


Physical agents
1.

Sunlight

2.

Drying

3.

Dry heat

4.

Moist heat

5.

Filtration

6.

Radiation

7.

Ultrasonic & sonic vibrations

Chemical agents
1.

Alcohols

2.

Aldehydes

3.

Dyes

4.

Halogens

5.

Phenols

6.

Surface active agents

7.

Metallic salts

8.

Gases


1.Sunlight


Bactericidal & germicidal



U.V rays & heat rays

2.Drying


Moisture- bacterial growth



Spores- unaffected



3.Heat

Most reliable


Factors

1)

Nature of heat-

2)

Temperature & time

3)

Number of microorganisms

4)

Characteristics of organisms

5)

Type of material from which the organisms - eradicated

1.Nature of heat
Dry Heat

Moist Heat

• Coagulation of Proteins
•

Electrolytes

•Denaturation &
Coagulation of Proteins

• Oxidative damage

2.Time & Temperature


Time α

1
Temperature

Thermal Death Time

“Minimum time required to kill a suspension of
organisms at a predetermined temp in a specific
environment”

3. No of Micro-organisms


Sterilization time

α No of Microorganisms

4.Characteristics of Microorganisms
Sterilization time

Spore

α Strain

5.Type of Material - Host
Organic Content

Spore

Difficult to Eradicate

Heat
Dry Heat

Moist Heat

1.Flaming

1.Pasteurization

2.Incineration

2.Boiling

3.Hot air oven

3.Steam
4.Autoclave




Flaming


Bunsen flame – Red hot
 Forceps point
 Spatulas
 Scalpel
 Needles




Incineration
 Burning
 Solid dressings
 Bedding
 Pathological material




Hot air oven


Widely used – 160ºC / 1 hr



Electricity



Even distribution of air



Dry


Forceps



Scissors



Scalpels



Syringes



Swabs

Moist Heat


Pasteurization (< 100ºC)  63 ºC / 30 min


Non-sporing MO


TB-Bacilli



Brucella



Salmonella




Boiling (100ºC)





x

 Disinfection

Surgical Instruments

Steam (> 100ºC)


Steam

Condenses to Water

Microbicidal Activity

Liberate Latent Heatwww.indiandentalacademy.com

Steam at atmospheric pressure


Free steam-culture media



90 mins



Sugar containing medias  100ºC / 20 mins



3 successive days  Tyndalisation


Steam Sterilizers


Types


Lab Autoclaves



Hospital dressing sterilizer



Bowl & Instrument sterilizer



Rapid cooling sterilizer


Autoclave


Principle  > 100ºC Under pressure
Pressure - Inside Closed chamber

Temperature

Saturated Steam
Penetrating power




Materials


Instruments



Dressings



Lab ware
Types of Autoclaves

High vaccum

Downward displacement


High vaccum

Vaccum suction

Downward displacement

Steam enters top of chamber

Air – Evacuated

Downward displacement of air

EX- Central Sterile supply
units in hospitals

EX- Automatic Bench top Autoclave

Sterilization Cycle
1.

Heating Period

2.

Holding Period

3.

Cooling Period


Sterilization Efficacy (Monitoring)


Spores of Bacillus Stearo-thermophilus


Time-Temp
Temperature

Holding Time (Min)

120ºC

15

126ºC

10

134ºC

3


Filtration


Heat labile substances


Antibiotic solutions



Sera



Carbohydrate solution

Types-Candle filters
-Asbestos filters
-Sintered glass filters
-Membrane filters

Radiation


Ionization




X-rays, γ-rays, cosmic rays  Highly lethal to DNA

Non-ionizaion


EMR  wavelength > visible light


Ex- IR, UV.



 Hospital wards, OT

Ultrasonic's & Sonic rays


High frequency of sound waves beyond the
range of human ear.



Variable sensitivity towards Micro-organisms



Commonly used in dentistry.

Chemical Sterilization


Chemical agents – Requirements

1.

Wide spectrum

2.

Active – Organic matter

3.

Speedy Action

4.

High penetrating power

5.

Stable

6.

Non-corrosive

Mode of action


Protein coagulation



Disruption of cell-membrane



Removal of Sulfates groups



Substrate competition (Competitive Inhibition)

Types of Chemical agents


Alcohols



Aldehydes



Dyes



Halogens



Phenols



Surface actives agents



Gases



Metallic salts



Alcohols


Ethyl alcohol & Isopropyl alcohol

 Skin Antiseptics
 60-70%
 Denaturation of Proteins
 No action on spores




Sterilium


Bacteria,antibiotic resistant bacteria,tubercle
bacilli,fungi,viruses



Composition
2 propanol-4.5gm
1propanal-30gm
ethyl-hexadecyl-dimethyl



Aldehydes
 Formaldehyde
 Against Amino group in Protein Bactericidal &

Sporicidal
 Preserve anatomical specimen's
 10 % formalin

 Gluteraldehyde
 Similar to Formaldehyde
 Effective against TB-bacilli, fungi & Virus



Korsolex


Total bactericidal,fungicidal,tuberculocidal,sporicidal,

viricidal(HBV,HIV,polio etc)


Mainly contains gluteraldehyde-7gm/100gm,rust
inhibitor



Ortho-pliers, cutters,arch wires

Chemical sterilization for
Orthodontic appliances


Bands  Plastic boxes – Dipping gluteraldehyde



Least critical Instruments  Soaking in 2%
Gluteraldehyde (100 mins)





8% Formaldehyde in Alcohol
2% Aqueous soln of Activated Gluteraldehyde

Removable 

Immerse Iodophors / Chlorine

Dyes


Anilines



Acridine


Bacteriostatic (High dilution)



Bactericidal (Low dilution)


Halogens


Iodine (Aqueous / Alcoholic soln.)






Skin disinfectant
Bactericidal & Moderately Sporicidal

Chlorine


Water supply



Swimming pools



Food industry


Phenols


Coal tars – Lister



Cell membrane damage



Microbicidal


Hospitals



Ex – Chlorheixidine  G +VE

Gases


Ethylene oxide



Heart , lung machines, respirators, dental equipments





Colorless – highly penetrating gas – all type of MO
Explosive

Formaldehyde




Fumigation of OT

β- propiolactone


More effective for fumigation



Low penetrating power

Surface active agents


Wetting agents, Detergents & Emulsifiers
1.

Anionic (Soap)

2.

Cationic

3.

Nonionic

4.

Amphoteric




Commonly used  Cationic – Cell membrane
Alkaline pH

Metallic Salts


Action α CONC



Salts of Heavy mestals – greater action



Salts of Hg, Cu, Ag  Disinfectants


Stages of sterilzation


Pre-sterilzation cleaning



Packing



The sterilization process



Aseptic storage

Pre-sterlization cleaning


Remove-contaminated instruments



Heavy duty household gloves,eye shields&face
masks-cleaning.



Sharps-carefull



Needles- capped.

 In dentistry
 Methods
 Manual scrubbing
 Ultrasonic cleaning.


Cleaning efficiency



Aerolization



Sharp injuries

Packing


Open tray system-sealed - bags



Perforated trays-fitted covers



Individual packing-bags


Sterilization process (Dentistry)


Moist heat(autoclave)



Dry heats



Gaseous chemicals(chemiclave)


Glass bead Sterilizer
218-246ºC for 3-5 seconds
Glass beads 1.2 – 1.5 mm
Hottest pasrt 

Peripherally

Larger the instruments

 Longer the

time

Chemiclave


Formaldehyde+alchohol+acetone+ketone+steam
-138kpa-127ºC



Dual-toxic chemicals – heat – 30 mins



Faster



Non corrosive.

Autoclave
Sterilization
cycle
Residual
moisture
Long term
effect on
instruments
Cycle
interuption

Chemiclave

Hot-air oven

Short
(3-30 mins)
Present

Intermediate
(30-45 mins)
Present

Long (> 60
mins)

Corrosion /
Rust

Minimal
Corrosion /
rust

Temper /
Brittleness of
Sharp edges

Not possible

Not possible

Possible

Chemical
hazards

Spontaneous
combustiion of
vapor >125ºC

Other hazards Nil


Nil

Monitering Sterilization


Process / Chemical Indicators





Liquid / Paper
Assure the efficacy of Sterilization cycle

Biological Indicators


Prove the Sterilization



Bacteriospores – Placed – most difficult areas



Weekly based

Storage of Sterilized Instruments


Sterilized instruments  Stored in a sterile state



Closed protected area of clinic with minimal air
flow – Cabin / Drawer


Office Disinfection/ Lab asepsis


Wipe – 70% Isopropyl alcohol


Chair



Table



Light handles



Spittoon



3 way - Syringe



Hand piece
 Straight tubing
 Non-retraction valve
 Minimize the no of tubing & wires
 Flush with running water-20-30sec
 Sterilization-autoclave,dry heat,chemical

Impression disinfection


Immerse –



4% Formaldehyde (10 mins)





0.5 – 1% Sodium hypochlorite ( 60 mins)
Gluteraldehyde

Spraying


0.5% Chlorhexidine in 70% Alcohol



UV – Disinfection unit



Antiseptic alginate impression material

Disposal of Waste


Sharp instruments & Needles, tissues / blood 
Disposed with special Precaution



Disposable Needles, scalpels / other sharp items
 Placed into Puncture resistant container



Clinical

+

Domestic waste

Classifcation of Dental instruments
1.

Critcal Instruments
-Surgical / Penetrating mucosa
-Scalpels, Burs, Scalars, chisels
-Bands, Band-removers, Ligature directors, band
forming pliers

1.

Semi-Critical
-Instruments touching mucosa
-Mirrors, Retractors

3.

Non-critical
-Ligature tire, Distal end cutters, tying pliers

ADA-Reccomendations for Infection control in
Dental office –JADA 1996

Instruments

Autoclave

Hot air oven Chemiclave

Burs

_

++

++

Handpieces

++

_

+

Impression
trays

++

+

++

Mirrors

_

++

++

Saliva ejectors

_

_

_


Orthodontic
pliers
-High quality SS

++
-Low quality SS
_
-With Plastic parts _ _

++
++
__

++
++
__

Water air
syringe tips

++

++

++


Studies on Infection
control in orthodontic
office

Sterilization & Disinfection in
Orthodontic office – a practical
approach
-Payne GS , AJO 1986

Rinsing in Running water
Draining

Ultrasonic cleaner – 5 mins

Running water

Dried

Alcoholic solution – remove residual water

Dry
Chemiclave - 20 mins


Glass bead Sterilization of
Orthodontic bands
-Smith GE, AJO 1986


Purpose of Study
1.

Determining bead sterilization – Ortho bands

2.

Minimal time – bands inoculated – bacteria &
spores

3.

Compare bead sterilization with other methods for
sterilizing orthodontic bands



10 bands – bacillus subtilis spores / staph albus



10 controls- Inoculated –nt in sterilizer



Bands placed 1 at a time


226ºC -15, 30, 45, 60 secs



BHI broth - 37ºC / 3 days




Results :-



15 secs – Bacterias



45 secs – Spores



5 bands – simultaneously – twice the time



Other techniques


5 sec tap water rinse



10 sec soap scrub



30 min – alcohol flame

Ineffective in killing
Bacteria & spores

Sterilization of Orthodontic
Instruments & Bands in Cassetes
Hohit WF et al 1990 AJO


OMS-ASAPsys Cassette
Contaminated instruments  Dried

Placed in cassettes

Ultrasonically cleaned

Rinsed & Dried


Steam, Chemical vapor, Dry heat

Instruments  Cultured

Results
1. Residual spores – Ultrasonic's – Killed
2. 3 Types of Sterilization  Equally effective


Effect of clinical use &sterilization
on selected orthodontic arch wires
Smith GA et al 1992, AJO


Study method



3 types of nitinol,1type of β-titanium,1-stainless
steal wires-clinically treated



20 wires



5 wires-control(unused)



Autoclave,cold sterilization,disinfection,dry heat



Subjected-load deflection,tension,corrosion tests



Results



No clinical significance-property-new&used


Comparison of 3 dry heat covection
sterilizers
1.
2.
3.

Cox Sterilizer
Dentronix –DDS
Feberware

Carcao G JCO 1993: 27 ; 259

1. Spores  All the 3 units  100%
2. Tested for Hardness
Surface discoloration
Dulling
Hinge looseness


Effects of 3 types of Sterilization on
Orthodontic pliers
- Mazzocchi AR, JCO 1994


Design  Testing Distal end cutters & Ligature cutters
– 500 cycles of Autoclave, Chemiclave and dry heat
sterilization



Each instrument was checked for


Hardness



Surface discoloration



Tarnish

 Before & After Sterilization




Results


All cutters -

Hardness – Greatest (Autoclaved )
-Least (Dry heat)

Surface discoloration
Worst discoloration

- All Pliers

 Chemiclave instruments


Infection control in orthodontic
office in CANADA
-Mccarthy GM et al , AJO 1997



Comaprison of Infection control methods
Between General Dentists and Orthodontics


Orthodontists

General Dentists

Gloves

85%

92%

Masks

38%

75%

Protective eye wear

60%

84%

Changing gloves
after each patient
Heat sterilization of
hand piece
Hep B vaccination

84%

96%

57%

84%

94%

92%

Addn Precaution HIV

80%

78%


Blood & Hepatitis B Contamination
through aerosols during debonding
-(Toroglu MS et al, Angle Orthodontist 2003, vol 73, 571)
Study design:-26 Patients (16 yrs)
-Aerosol samples collected – Saliva ejectors
-Serum, excess fluid and aerosol samples of 3 hepatitis B
carrier is tested
-ELISA / PCR



Results


Blood – All aerosols & Excess flluids



Hbs Ag – 2 Hepatitis B Carriers



HBV – DNA  1 excess fluid sample



Both  1 hepatitis B carrier


HIV – HBV  Special Precaution


Routes of transmission – Dentistry
 Blood
 Aerosols
 Rotary instruments
 Saliva

Evidence ????????

Precaution
1. In relation to Blood – Body fluids


Barrier methods

2. In relation to Injection & Skin Piercing


Needle – Extra care
-Disposed in Puncture proof container

3. Effective use of Sterilization & Disinfection
Autoclave
 Dry heat
 Chemiclave
 Gluteraldehyde



References


Essential microbiology for dentistry-L.P
samaranayake



Text book of microbiology-Ananthanarayan&paniker



Medical microbiology- Satish gupte



Principles of endodontics- Grossmen



Comparison of 3 dry heat convection sterilizers-George carcao,JCO-1993



Bead sterilization of orthodontic bands-Jerald E
smith, AJO1996



Effect of 3 types of sterilization on orthodontic
pliers-Mazzocchi etall, JCO1994



Possibility of blood & hepatitis contamination
through aerosoles generated during debonding
procedures-Toroglu et all, AJO2003



Sterilization &disinfection in orthodontic office: A
practical approach-Payne s, AJO1986



Infection control in orthodontic office in canada-Mc
carthy et all AJO1997



Effect of clinical use & sterilization on selected
orthodontic arch wires-Glenn et all AJO1992



Infection control recommondations for the dental
office & dental laboratory-Assosiation report
JADA 1996



HIV disease in India-Hand book for dental
proffesionls- D.C.I publication


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