INFECTION

CONTROL IN
OPERATIVE
DENTISTRY
By: LIKITHA.D AND M.MADHUMITHA
INTRODUCTION
 INFECTION CONTROL HAS BECOME AN INTEGRAL PART OF
DENTAL PRACTICE.

 Earlier simple methods like immersing instruments in disinfectant

solutions, or boiling them before use were followed.

 However, presently there are clearly defined techniques and protocols

for sterilization of various materials and instruments used during
restorative treatment.
 IN DENTISTRY, we generally deal with ambulatory, relatively healthy patients who
may carry many infectious diseases unknowingly.
 Also, the dentist or any member of his staff may be suffering from some infection.
 These infections may be transmitted from the patient to the dental staff or vice
versa, or from patient to patient (cross infection).
 Of particular concern are upper respiratory tract infections, Herpes simplex,
Tuberculosis, Hepatitis B, etc., being transmitted during dental treatment.
 With the current attention focused on acquired immunodeficiency syndrome
(AIDS), Hepatitis B and other potentially life-threatening diseases, infection control
has become an important step during all treatment procedures.
 It is therefore essential that all members of the dental team have a clear
understanding of infection transmission and various methods of controlling the
same.
DEFINATIONS
 SEPSIS: The presence of pathogens in blood or other tissues.

 ASEPSIS: The prevention of contact with pathogens. In dentistry this

includes the technique of barrier protection, sterilization and disinfection.

 STERILIZATION: The destruction of all forms of life including the most

heat resistant bacterial spores. Practically, sterilization denotes the use of
physical and chemical agents to eliminate all viable microorganisms,
including bacteria, fungi, virus and spores.

 DISINFECTION: The destruction of pathogenic agents by directly applied
physical or chemical means.

 ANTISEPTICS: Agents that prevent the growth or action of

microorganisms on living tissues.

 DISINFECTANTS: Chemicals capable of killing pathogenic organisms when

applied to inanimate objects.
ROUTES OF
TRANSMISSION OF
DENTAL INFECTIONS
 In the dental operatory infections can be transmitted through direct
contact with blood, saliva and other secretions.

 Indirect contact with contaminated instruments or equipments.

 Through contact with airborne contaminants.

 The various routes of microbial transmission include:

1) 2) INHALATION
INOCULATION
 INOCULATION – Direct contact of previously damaged skin or mucous
membrane with a lesion, organisms or debris while performing intraoral
procedures is one route for entry of microorganisnms.

 Injury due to a contaminated needle, sharp instruments or flying debris

from the oral cavity is another means of inoculation.

 INHALATION – While using high speed dills or ultrasonic scalers,

microorganisms aerosilized from the patient’s blood or saliva can be
inhaled.
PERSONAL PROTECTION
TECHNIQUES IN THE DENTAL CLINIC
 Since there are many sources of potential infection in the dental office,
certain protective methods are mandatory to prevent both the dentist and
the patient from contacting infectious or hazardous materials.
 These include:

1.PERSONAL HYGIENE:
 While treating patients, the dentist and his team must follow a rigid code
of hygiene to minimize cross infection. It is important to avoid touching
their eyes, nose, mouth, etc. Any cuts should be covered with dressings.
2.PROTECTIVE OVERGARMENTS:
 A cotton or synthetic fiber overgarment worn over the dentist’s clothes
provides protection against spatter from routine work. This should be worn
only in the clinic area and must be laundered on a daily basis.
3.BARRIER PROTECTION:

•Hand washing –
 Meticulous hand care can prevent the transmission of infections to a major
extent. Thorough hand washing must be done before and after each patient
using a mild antiseptic such as 3% p chlorometaxylenol (PCMX) or 4%
chlorhexidine gluconate. This can control transient pathogens.
 Hand washing is also necessary while changing gloves as even good quality
gloves may have minor pinholes or leaks.

•Treatment gloves –
 The clinician must wear treatment gloves during all treatment procedures as
there are chances of contacting the patient’s blood, saliva, or mucous
membrane which may transmit infection from the patient to the dentist. Fresh
gloves must be used for every patient.
 Torn or punctured gloves must be discarded immediately.
•Protective eyewear, masks and hair protection-
 The operator must protect his eyes from spatter by wearing protective
glasses with solid side shields.
 These can be disinfected between patients.
 Face shields are required when there is heavy spatter such as during
ultrasonic scaling, crown and bridge preparation, etc.
 Mouth masks are a must to protect the dentist’s oral and nasal mucosa
from aerosol and spatter of blood or saliva.
 Rectangular masks with folds have the highest filtration rate. Masks must
be changed whenever they become moist or visibly soiled.
 The operator’s hair has to be kept away from the treatment field by
means of a surgical cap.
•Over gloves –
 These are made of lightweight, inexpensive, clear plastic.
 They are put over treatment gloves while handling cabinets, answering the
telephone, making entries in the dental chart, etc. so that treatment gloves are not
contaminated.

•Rubber damn isolation and high volume evacuation-

 There have been reports of transmission of various airborne infections from aerosol
and spatter during use of rotary equipment.
 Hence use of high volume evacu ation and rubber dam isolation is valuable in
controlling infection transmission.
 It has been reported that high volume exacuation can control upto 80% of the
contamination pro duced by aerosol.
•Pre-procedural mouthrinse –
 A chlorhexidine mouthwash (0.1 to 0.2%) prior to treatment greatly reduces
the intraoral microbial load and the risk of cross infection from patient to
dentist.


4.HANDLING OF SHARP INSTRUMENTS AND NEEDLES:

 In operative dentistry, numerous objects with sharp edges such as needles,
blades, burs, matrix bands etc., are employed to perform various procedures.

 Whenever possible, manual handling of sharps should be avoided; forceps or

other appropriate means should be used to handle them.
 Extreme care should be taken during recapping of needles in order to
prevent needle stick injuries.
 Instead of manual recapping, a special holder may be used or the cap may
be placed in the instrument tray itself with the needle carefully guided into
it till it is completely seated.
 In the event of any injury due to sharp items, proper protocol should be
followed.

5.IMMUNIZATION:
 The dentist and his team should be vaccinated against common illnesses
such as Tuberculosis, Rubella, Measles, Varicella, Mumps and Diptheria.
 Vaccination against Hepatitis B virus is strongly recommended for all
clinical staff.
OPERATORY ASEPSIS
 The dental operatory must be maintained spotlessly clean. The items in the
dental operatory can be categorized into three groups:
 1.Critical items:

 These include instruments that contact cut tissues or those that

penetrate the soft tissues. Eg. Needles, scalpels, endodontic instruments.
 2.Semi critical items:

 These include all instruments that enter the patient’s mouth. These also
include items
 attached to the dental unit which are used intra-orally during treatment.

 Eg. Air/water syringe tip, suction tips, handpieces. Some other items that are
handled during treatment like lamp handle, switches, chair control buttons are
also considered semicritical.
3.Non-critical items:
These are environmental surfaces such as chairs, benches, floors, walls and
supporting equipments of the dental unit which are not ordinarily touched during
treatments.
The requirements for these three categories of items. They are:
 i) All critical items must be sterile at the time of use.
 ii) Semicritical items like instruments, handpieces also need to be sterilized before
use.
 iii) Some semicritical items like lamp handles, switches, etc., which are handled
during treatment require cleaning with a disinfectant between every patient.
Nowadays these items are covered with cling film or aluminium foil and changed
between each patient to ensure cleanliness.
 iv) Contaminated non-critical items may be cleaned and disinfected.
PROCEDURES BEFORE
STERILIZATION
 All contaminated instruments should be soaked and then cleaned before
being sterilized.
PRESOAKING OF INSTRUMENTS
 Contaminated instruments are kept soaked in a chemical disinfectant like
gluteraldehyde or synthetic phenol for 30 minutes. This will prevent blood
and saliva from drying on the instruments thus facilitating cleaning.

PRESTERILIZATION CLEANING OF INSTRUMENTS

 After soaking the contaminated instruments for some time, they must be
thoroughly cleaned before sterilization in order to remove gross organic
debris, blood and saliva.
 Cleaning can be done by:
 1) Manual method: Wearing protective utility gloves the instruments may be
cleaned using a hard brush with stiff bristles along with a detergent solution or
using soap and water.

2) Ultrasonic method: Ultrasonic cleaning is much more effective and safer

than hand cleaning. Presoaked instruments may be immersed in an ultrasonic
cleaner .This operates at 40°C and 35 KHz, and is filled with a detergent solution.
Instruments are kept in this bath for 5 minutes.
Ultrasonic cleaners employ piezoelectric oscillators situated underneath stainless
steel enclosures to create oscillations in a fluid-filledtank. The cavitation effect
produces microscopic bubbles that effectively clean inaccessible areas on
instrument surfaces.
 After cleaning, the instruments are rinsed under

running water to remove any residual detergent and

dried thoroughly before sterilization.
STERILIZATION
 This is the process by which there is complete destruction of all microbial
life (including spores and viruses) from an article.
 Most instruments used in dental clinics contact mucosa and/or penetrate
oral tissues.
 In order to ensure effective infection control, they must be cleaned and
sterilized by accepted methods before reuse.
 There are four accepted methods of sterilization:
 1. Steam pressure sterilization (Autoclave).
 2. Dry heat sterilization (Dryclave).
 3. Chemical vapour pressure sterilization (Chemiclave).
 4. Ethylene oxide sterilization.
1. STEAM PRESSURE
STERILIZATION/
AUTOCLAVING
 The steam autoclave is most commonly used for sterilization.

 This uses superheated steam under pressure and works on

the same principle as a pressure cooker.

 It consists of a double-walled chamber to hold the instruments and steam

circulates under high pressure.

 Moist heat kills microorganisms by protein coagulation and breakdown of

DNA and RNA.
Requirements for proper autoclaving:
 Wrap instruments in thin cloth, paper, steam permeable plastic or
perforated cassettes.

 Impermeable closed containers are not recommended.

 Instruments and packages must be properly arranged to allow free circulation

of the pressurized steam.

 Use fresh distilled water for each cycle. Tap water should not be used as it
contains minerals that can form deposits on the inner surface of the
autoclave.
 Carbon steel instruments and burs should be dipped in a corrosion-inhibitor
solution (2% sodium nitrite) before being wrapped. This will prevent them
from corroding.
 Sterilization will not occur unless the autoclave is operated at the appropriate
pressure and temperature for an adequate length of time. Optimum pressure
and temperature must be reached before timing the sterilization cycle.
Types of autoclaves
 1. Downward displacement autoclaves- They cause downward
displacement of air as steam enters the top of the chamber. Their efficacy
is low.

 2. High vacuum autoclaves– They are also known as rapid cycle

autoclaves.
 In these, air is evacuated by vacuum suction before steam enters the
chamber.
 These autoclaves perform rapid and effective sterilization than
conventional autoclaves and are presently popular in dentistry.
2. DRY HEAT
STERILIZATION/DRYCLAV
E
This method effectively sterilizes instruments at high temperatures above
160°C, but more time is required to warm-up the instrument load.
 The apparatus is a dry heat oven which has heated chambers to allow air
to circulate by gravity flow (gravity convection).
 Dry heat kills microorganisms by an oxidation process.
 As it is very slow in penetrating instrument packs, they must be placed at
least 1cm apart to allow the heated air to circulate.
 To speed up the sterilization process, mechanical convection ovens are
available that circulate the air rapidly by means of a fan or blower.
 The instruments should be wrapped lightly in aluminium foil. Paper and
cloth packs should be avoided as they may char.
3. CHEMICAL VAPOUR
PRESSURE
STERILIZATION/
CHEMICLAVE
 This method employs chemical vapour under pressure for sterilization.

 The apparatus is similar to the autoclave but uses mixture of

formalydehyde, alcohol, ketone, acetone and water.

 When this solution is heated under pressure it forms a gas that sterilizes
instruments. The chemical vapour kills microorganisms by destroying vital
protein systems.

 Instruments are packed in paper, muslin or steam-permeable plastic. The

sterilizer must be preheated before use.
4. ETHYLENE OXIDE
STERILIZATION
 This method uses automatic devices filled with ethylene oxide gas at
temperatures below 100°C to sterilize complex instruments and delicate
materials.

 Ethylene oxide is highly penetrable and kills microorganisms by chemically

reacting with nucleic acids.

 The sterilization cycle takes several hours and once over, aeration for 24
hours or more is needed before the instruments can be used.
5. NEWER METHODS OF
STERILIZATION
 Several newer methods of sterilization are employed for specific purposes.

 Gamma rays are used to sterilize suture materials, syringes, disposable

needles and other heat sensitive items.

 Ultraviolet light is used to purify the air in the dental operatory but it is not
very effective.

 Hydrogen peroxide vapour, gas plasma sterilization and the use of lasers
are still under investigation but are not yet practical for dentistry.
STORAGE AND CARE OF
STERILIZED
INSTRUMENTS
 Once sterilized, instruments should be maintained in a sterile state until
use: improper storage would break the “chain of sterility”.

 A closed cabinet or drawer with minimal air flow that can be easily
disinfected is preferred over an open stacking system.

 Ultraviolet chambers are also used to store sterilized instruments.

MONITORING
STERILIZATION
 There are two methods of verifying sterilization: i) Process indicators. Ii)
Biologic indicators.
 i) Process indicators are strips, tapes or paper marked with special ink that
that change colour on exposure to the appropriate sterilization cycle.
However, they do not guarantee complete sterilization.
 Ii) Biologic indicators are non-pathogenic bacterial spores attached to a
paper strip within a biologically protected packet. If the sterilization method
destroys spores then it is effective against all other organisms. After
sterilization, the spore strip is cultured for a specific time. If there is no
growth then the sterilization is successful. The organisms used are spores of
Bacillus stearothermophilus or Bacillus subtilis. Biologic indicators are the
most accurate test for verifying sterilizer efficacy. Biologic monitoring should
be done on a weekly basis to check the functioning of the sterilizer.
Ultraviolet chamber
HANDPIECE
STERILIZATION
 Dental handpieces are semicritical items.
 While using the handpiece in the patient’s mouth, blood, saliva, tooth cutting
debris and restorative materials may be drawn into its working portion.
 Hence handpieces have to be properly sterilized between patient exposures
to prevent cross infection.
Protocol for sterilizing handpieces:
 1. Prior to removing the handpiece from the dental unit, clean it by wiping
visible debris using a suitable disinfectant such as alcohol.

 2. Following this, run it for a minimum of 30 seconds to discharge residual

water and air.
 3. Next, clean the handpiece thoroughly with a soap or detergent solution.

 4. Now reattach handpiece to the unit and run dry.

 5. Most handpieces should be lubricated before sterilization using a

lubricant delivered from an aerosol can through an adapter.Excess
lubricant should be expelled. An automatic handpiece cleaning unit
connected to the air supply can also be employed to clean and Iubricate
the handpiece. This is more efficient than the manual method.

 6.Finally, place the handpiece in a paper pack and seal it.

 7. Now the handpiece can be sterilized by autoclaving.

 8. Some manufacturers recommend lubrication after sterilization but the

handpiece should be run briefiy before use to clear the excess lubricant.
 STERILIZATION METHODS:
 Hand pieces can be effectively sterilized by means of the autoclave or by
ethylene oxide sterilization.

 These methods are safe provided the handpiece has been thoroughly
cleaned and oil for lubrication is completely cleared out.

 To minimize problems like loss of torque, turbine wear, etc., the

manufacturer’s instructions should be strictly followed.
DISINFECTION
 This term refers to the destruction of pathogenic agents by physical or
chemical means.

 Disinfectants are used for soaking contaminated instruments prior to

cleaning and sterilization.

 They are also used to clean some semicritical and non-critical items
between patients.
1. BOILING WATER
 This is a physical means of high level disinfection.
 It is employed when sterilization by other means is not possible.
 Eg. When there is a sterilizer breakdown.
 Instruments have to be cleaned well and completely submerged in boiling
water at 98°C to 100°C for 10 minutes.
 This method can destroy blood borne pathogens but not spores. It also
causes rusting of instruments.
2. GLUTERALDEHYDE
 This is a commonly used chemical dinsifectant.
 At concentrations of 2-3% it provides high-level disinfection for heat
sensitive items. Eg. Heat sensitive plastics, rubbers, etc.
 It destroys microorganisms by altering essential protein components.
 It is used for presoaking of instruments before cleaning and sterilization.
3. SODIUM
HYPOCHLORITE
 This is another chemical disinfectant used for surface disinfection of non
critical items in the dental operatory.
 A diluted 1.5% solution of sodium hypochlorite can be applied over the
surfaces for 10 to 30 minutes.
 It is biocidal against bacteria and viruses and acts by denaturing proteins.
 However, sodium hypochlorite has a strong odour, irritates skin and eyes
and is corrosive to metal.
4. IODOPHORS
 These are combination of iodine and a solubilizing agent.
 Diluted with water they release some free iodine which can destory
bacteria, viruses and some spores.
 This can also be used for surface disinfection and must be applied for 10
to 30 minutes.
 Iodophors are less corrosive to metals and less irritating than hypochlorite.
5. OTHERS
 Other chemical disinfectants include alcohols,phenolics and quarternary
ammonium compounds but these are inferior to gluteraldehyde, sodium
hypochlorite and iodophors.
DENTAL WATER LINE
CONTAMINATION AND
BIOFILM
 Dental unit water lines may be contaminated by biofilm.
 Biofilm is the colonization and proliferation of microorganisms on surfaces
bathed by fluids.
 Since the flow rate in dental unit waterlines is very low, biofilms can readily
form here.
 As a result the water emitted from handpieces and air/ water syringes may
have high concentrations of microorganisms some of which may be
pathogenic.
 While using handpieces, these organisms can be introduced into the
patient’s oral cavity from where they have the potential to initiate systemic
infections.
There are various ways to reduce the formation of biofilms:
1. Periodic flushing of dental unit water lines: This is done with sterile
water or 1:10 dilution of 5.25% sodium hypochlorite is recommended. A
minimum of 20 to 30 seconds of flushing of waterlines between patients is
recommended by the Centers for Disease Control.
2. Filters and antiretraction valves : These may be installed in the
waterline as close as possible to the point of use. They can prevent the
retraction of fluid back into the tubing.
 3. Use of sterile water delivery systems: This can also reduce the risk
of transferring potentially infective organisms.
INFECTION CONTROL FOR
IMPRESSIONS AND OTHER
PROSTHETIC ITEMS
 Impressions, records, stone casts, dentures, etc., which have been placed in the
patient’s mouth can transfer infection to laboratory personnel.
 So it is important to decontaminate these items before they are transferred to the
dental laboratory.
 The following steps have to be taken:
 1. Thoroughly wash the impression or other prosthetic items under running tap water
to remove saliva, blood and debris.
 2. Disinfect the surface of most items including elastomeric impressions by
immersion in 2% gluteraldehyde or chlorine compounds for 10 minutes. The time of
immersion varies according to the manufacturer’s instructions.
 3. For alginate impressions, spray an iodophor as soaking may distort the
impressions.
 4. Store the items in separate sealed plastic bags before transfer to the laboratory.
DISPOSAL OF WASTE
 All clinical waste materials like contaminated disposables (masks, gloves),
blood/saliva-soaked cotton rolls, etc., must be carefully discarded in sealed
plastic bags to minimize human contact.
 Sharp items like needles, scalpel blades, etc., must be stored in puncture-
resistant containers before disposal in plastic bags.
 Local environmental protection or control agencies regulate the disposal of
blood contaminated wastes.
INFECTION CONTROL
CHECKLIST
At start of the day/session Check functioning of autoclave.
 Before patient treatment

 Ensure that all equipment has been sterilized or adequately disinfected (if it cannot be
sterilized).
 Put disposable coverings in place where necessary. Place only appropriate instruments on
bracket table.
 Arrange all materials and essential items on trolley.

 Update patient’s medical history.

 During patient treatment Treat all patients as potentially infectious.

 Wear gloves, masks, protective eye wear and protective clothing.

 Wash hands thoroughly before gloving. Use a new pair of gloves for each patient. Change
gloves immediately if they are torn, cut or punctured.
 Use rubber dam to isolate and high volume aspiration when required. Ensure good ventilation
of treatment area.
Handle sharps carefully and re-sheath needles using a suitable device.
After patient treatment
Dispose of sharps via the sharps container. Segregate and dispose of clinical waste.
Clean instruments thoroughly before placing in an ultrasonic cleaner. Sterilize cleaned
instruments using an autoclave and store appropriately.
Clean and disinfect impressions and other dental appliances before sending to laboratory.
Prepare the operatory area for the next patient.
At the end of the day
Dispose all clinical waste from the surgery area.
Clean and disinfect all work surfaces thoroughly. Disinfect the aspiration, its tubing and the
spitoon.
Clean the chair and the unit.
 Drain autoclave chamber and water reservoir and leave to dry.
CONCLUSION
Adequate asepsis is a highly critical step in treatment.
Sterilization procedures used in dentistry should be simple, effective and of
relatively short duration so that there is a readily available supply of sterile
instruments and other materials.
The procedures should not cause any appreciable damage to dental
insturments and materials.
 The sterilization processes must also be properly monitored.