Practical class №4

Disinfection and sterilization. Safety rules when working with dental equipment.
Care and maintenance of dental equipment. Emergency situations in dental
practice.

The main measures limiting the spread of the infection at a dental appointment are aseptics
and disinfection with antiseptics closely related. Key notions in this sphere are as follows.
Aseptic means the state of being free from disease-causing contaminants (such as bacteria,
viruses, fungi, and parasites) or preventing contact with microorganisms.
Antiseptics means all you have to do in order to destroy microorganisms in injury, organs
and tissues.
In 1890 at the Xth International Medical Congress in Berlin the basic postulate of asepsis
was adopted: all things that come in contact with injury must be sterile.
There are high degrees of pollution and microbial contamination; besides, dental instruments
are of rather complex configurations, lots of retention points and locking fasteners. Besides there is
a great variety of dental instruments and each one of them has a specific function, structure of
materials. That is why the choice of ways and methods of disinfection and sterilization requires a
differentiated approach.
Disinfection means destruction of most pathogenic and other kinds of microorganisms (but
not spores) by physical or chemical means.
Sterilization means a physical or chemical process that destroys all microorganisms,
including spores.
In 1968 E.H. Spaulding suggested dividing all medical products into critical, non-critical
and semi-critical items based on the degree of contact they have with patients and their risk of
disease transmission. In turn, their risk of disease transmission indicates how they should be cleaned
for reuse.
Critical items cut bone or penetrate soft tissue. These instruments carry the highest
risk.
Clean and heat-sterilize critical dental instruments before each use.
Whenever sterilization is inaccessible, disposable instruments should be used.
Semi-critical items touch only mucous membranes. They have a lower risk of
transmission.
► Clean and heat-sterilize semi-critical items before each use.
► For heat-sensitive critical and semi-critical instruments, reprocess using high-level
disinfectants or low-temperature sterilization method (such as ethylene oxide).
► Single-use disposable instruments are acceptable alternatives if they are used only once
and disposed of correctly.
Noncritical items only contact intact skin. They have the lowest risk of disease
transmission.
 Ensure that noncritical patient-care items are barrier-protected or cleaned (or if visibly
soiled, cleaned and disinfected) after each use with a hospital disinfectant. If visibly contaminated
with blood, use a hospital disinfectant with a tuberculocidal property (i.e., an intermediate-level
disinfectant).

Processing of medical instruments consists of several stages:

► disinfection;
► pre-sterilization cleaning;
► sterilization.
There are two possible ways of disinfection: physical and chemical.
Physical disinfection is processing using strong heat (boiling in distilled water or water
with an addition of sodium bicarbonate).
Chemical disinfection is processing instruments with chemical disinfectants. Chemical
fluids have different basic active substances and different spectrum of action. Chemical disinfection
is the method used most commonly nowadays.
Put the instruments put in the disinfectant tank immediately after use, so that they are
covered completely.
Instruments of complex configuration are disinfected unassembled. Channels and cavities
are filled with disinfectant solution so that they do not contain any air bubbles.
All chemical solutions should be used according to instruction (including the method of
solution preparation and time of exposure).
After that you should wash the instruments under clear running water and dry them.
The next step is pre-sterilization cleaning. Do it to destroy residual blood, fat and protein
contamination. There are two methods of pre-sterilization cleaning. The first is manual and the
second one is mechanical.

Fig. 5.1
Manual pre-sterilization cleaning includes several steps: exposition in washing solution, then
washing with a brush.
For mechanical pre-sterilization cleaning use automated cleaning equipment such as an
ultrasonic cleaner with disinfectants.
Pre-sterilization monitoring should be done at least weekly.
1% of all items processed during a dental shift are subject to checking the quality of
cleaning. Tests are made to detect residues of various contaminations: contamination with blood
and proteins - (azopiram/amidopirim test), residual alkali of washing solutions - phenolphthalein
test, residual fat - Sudan III test.
The results of inspection should be entered in the journal of checking the quality of pre-
sterilization cleaning.
The third step is sterilization proper. Although the instruments have been cleaned to remove
debris, they are not sterile.
Prior to physical sterilization the instruments should be packed.
Heat sterilization cabinet (hot dry air).
 Fig. 5.3
The most common mode is for 60 minutes at 180 degrees or for 150 minutes at 160 degree .
However, dry heat sterilization has its advantages and disadvantages. On the one hand, the hot dry
air does not permit any moisture to cause corrosion of instruments. On the other hand, this method
is time-consuming; besides, strong heat can damage instruments so you should not use it for
handpieces, mirrors and cutting instruments.
Steam sterilization is sterilization within an autoclave. In dentistry we commonly use
automatic machines with a rather small working chamber. The working mode for dental instruments
is at 132 degrees at a pressure of 2 atmospheres for 20 minutes, or at 120 degrees, pressure of 1.1
atmospheres for 45 minutes.
Due to its high efficiency, this method is widely used in medical practice. The method is
quite cost-effective and least harmful for the environment. Au-toclaving dental instruments and
materials is the most reliable and sometimes the only possible way of sterilization. However, it also
has some disadvantages: steam can transform to condensation which leads to corrosion of
instruments; besides, it can moisten the materials which increases the risk of reinfection of sterilized
products.
Sterilized and packed instruments should be stored in wardrobe cabinet or desk. Storage
time is indicated on the package.
There is one more type of physical sterilization: glass bead sterilization. The time of
exposure is 3-20 seconds and the temperature is 240 degrees Centigrade.
This method is used for quick sterilization of metal instruments as well as for express
sterilization of burs, endodontic instruments, metal matrix, inner canal pins. Do not use it to sterilize
other dental instruments.
Chemical sterilization of dental instruments uses aldehyde solutions and oxygenates.
Chemical sterilization should be done strictly according to instructions. All instruments should be
absolutely dry in order not to reduce the concentration of active ingredients in the working solution.
All boxes should be sterile. Sterilized products are put to use immediately or placed in storage in a
sterile filter sterilization box, lined with sterile sheets, for a period of no longer than 3 days.
If infection has begun to develop, we are talking about antiseptics. This term was proposed
in 1750 by a Scottish physician John Pringle, who found that mineral acids possess antiseptic
properties.
Types of antiseptics: mechanical, physical, chemical, biological.
► Mechanical (manual) antiseptics:
• removal of foreign body from the wound;
• necrectomy (removal of dead tissues which can also be the cause of infection).
► Physical antiseptics:
• providing a passive (with a rubber drain) or active (dressings or bandage with hypertonic
solution) outflow from the injury;
• aeration of injury (providing access of air to the injury to reduce the propagation of
anaerobic bacteria);
• UV irradiation;
• decontaminaitng equipment in combination with ultrasound;
 • microbicidal agent (causing bacteria to die): beta-lactam antibiotics, aminoglycosides,
glycopeptides, metronidozol;
• bacteriostatic agents suppressing bacterial reproduction: macrolides, tetracyclines.
► Biological antiseptics:
• bacteriophage is a virus selectively infecting bacterial cells, multiply inside bacteria and
causing their lysis;
• antitoxin means harmless toxin derivatives that retain its antigenic and immunogenic
properties. It is used to build active immunity against related infections (vaccination).

OPERATION AND MAINTENANCE OF DENTAL UNITS

To ensure long-term and trouble-free operation of dental units, it is necessary to follow the
rules of operation and ensure systematic maintenance. Technical maintenance plan
Before you start, you need to do the following:
► check the availability of water and the availability of sewerage;
► check the operation of the compressor and for the presence of liquids in the tanks;
► check the performance of instruments, handpieces and seats;
► clean the instruments, control panels, handles and switches, spittoon bowl and the surface
of the chair.
After each patient, you need to do the following:
► clean the instruments, control panels, handles and switches, spittoons and the surface of
the chair;
► replace the tips of the saliva ejector and vacuum cleaner;
► clean the spittoon bowl.
At the end of the working day it is necessary to do the following:
► clean the spittoon bowl and fill the sewage system with a disinfectant and cleansing
solution;
► disconnect the power supply from the unit, chair and compressor;
► shut off the water supply tap, thus disconnecting the unit from the water supply;
► release pressure from the compressor and the air system of the unit;
► release the remaining water from the hydraulic system of the unit;
► check for the cleanliness of instruments, control panels, handles and switches, spittoons
and the surface of the chair;
► drain condensate from the compressor receiver;
► check the oil level in the compressor crankcase and the automatic tip lubrication system
(if any);
► check the oil level in the hydraulic system (if the seat has a hydraulic drive);
► lubricate all swivel and roller connections.
Once a month it is necessary to perform full maintenance of the unit with involvement of
medical specialists.
Changes in the maintenance plan and operation are possible taking into account:
► intensity of equipment operation;
► recommendations of the equipment manufacturer;
► recommendations of service specialists - medical technicians and sani-tary-
epidemiological service.
In the event of a malfunction work on the equipment must be completely discontinued. Then
eliminate the resulting faults on your own or bring in troubleshooting specialists. After
troubleshooting, it is necessary to perform a full scan of the equipment, after which you can start
working again.

Dentistry is a specialty dangerous in the truest sense of the word.

At work dentists are prone to be affected by various dangerous and harmful factors:
► physical factors like electric shock;
 ► chemical factors like burns with potent drugs;
► biological factors like possibility of infection.
Therefore, it is necessary to show responsibility observing the safety rules.
The most important thing in case of any damage is to immediately discontinue the damaging
factor!
► Electric shock: turn off the unit immediately!
► Disengage the victim from the electric current by using a nonconductive object to free the
victim from the energy source without touching him or her directly!
► Perform cardiopulmonary resuscitation: clear the victim's airways by removing the
tongue!
► Aspiration of a foreign body.
► Maneuver: stand behind the patient, push the diaphragm from the bottom up with an
abrupt movement.
► Maneuver: raise the victim's arms up abruptly.
► Injuries to the patient and the doctor.
► Dental care institutions should be provided with first-aid kits for:
• emergency and first aid;
• emergency situations.
► All workplaces must be provided with a disinfectant solution and a first aid kit.
► The first aid kit for emergency situations when there is blood on the skin and mucous
membranes due to a puncture or cut should include:
• 5% alcohol iodine solution;
• 70 ° ethyl alcohol;
• cotton wool, bandage;
• adhesive plaster;
• 0.05 g potassium permanganate to prepare 0.05% solution;
• distilled water in 10 ml ampoules;
• a container for preparation of potassium permanganate solution;
• eye and nose pipettes;
• 30% sulfacetamide solution;
• 1% protargol solution;
• tourniquet;
• 10% ammonia;
• eye trays -2 pcs.
► If the infected material gets into intact skin areas:
• apply 70% alcohol to the skin;
• wash the area with warm water and soap and dry;
• repeat the treatment with alcohol. Do not rub the skin.
► If the infected material gets into damaged skin, you should:
• squeeze blood out of the wound;
• treat the wound with 5% iodine without using disinfectants.
► When working with HIV-infected patients, it is necessary to take 800 mg/ day of
thymoside for 30 days.
► When working with patients infected with hepatitis virus, to prevent infection, prescribe
drugs that stimulate the patient's own immunity.
► Levomax (tyloron) is an inducer of endogenous interferon, it stimulates formation of α-,
β-, γ-interferons in the intestinal epithelial cells, hepatocytes, and neutrophils. After oral
administration, the maximum production of interferon occurs in 4-24 hours. The drug has antiviral,
immunomodulating action. To prevent infection, the drug is taken at a dose of 0.125 g (1 tablet)
once a week for 6 weeks.
► Cycloferon is an immunomodulator; it increases the activity of the T-cell link of
immunity, normalizes the ratio of T-helper/T-suppressors. Regimen for prevention of HH: on day 1,
4 tablets simultaneously; on day 2, 4, and 6 , 2 tablets; after that 2 tablets once every 5 days during
the incubation period.
► In Russia vaccination against hepatitis B is included in the national vaccination schedule.
The following genetically engineered recombinant inactivated vaccines are registered in Russia:
• vaccine produced by the Kombirotekh company, Russia;
• vaccine Rec HBsAg by Cuban manufacturers;
• Engerix At SmithKline Beecham Belgium;
• H-B-Vax-II manufactured by Merck, Sharp, Dome, USA;
• vaccine Euvax manufactured by Pasteur Merier Connaught, registered by the Ministry of
Health of the Russian Federation on May 5, 1999.
► If the infected material gets into the labial mucosa or mouth:
• treatment with 0.05% potassium permanganate;
• rinse with 70% alcohol or 1% protargol.
► If the infected material gets into the eye mucosa:
• treatment with 0.05% potassium permanganate;
• injecting 1% solution of silver nitrate.
► If the infected material gets to the medical gown or other clothes, the affected area should
be immediately treated with one of the disinfectant solutions (active against hepatitis viruses with
parenteral transmission mechanism), then disinfect the gloves, remove the gown, soak it in one of
the solutions (except 6% hydrogen peroxide, neutral calcium hypo-chloride, which destroy the
tissue) or put into sterilization boxes for au-toclaving. Shoes are treated twice with a cloth wiped
with a solution of one of the disinfectants. The skin of hands and other areas of the body under
contaminated clothing is wiped with 70% alcohol.
► The artery is always fixed to the bone!
► When applying a tourniquet the time is always noted!
► You know that the tourniquet was placed correctly if there is no pulsation below the level
of fixing the artery.
► Points of compression of the main arteries in the maxillofacial area:
• facial artery is pressed to the body of the lower jaw along the anterior edge of the
masticatory muscle;
• temporal artery is pressed to the temporal bone along the anterior margin of the temporal
muscle;
• carotid artery is pressed to the transverse process of the 6th cervical vertebra.
► Prevention of injuries.
• Work with insulation!
• Never work without a stop!
• Press the pedal only when the bur is located directly at the tooth.
► Fire.
► Evacuation is carried out in accordance with the evacuation plan.

Sanitation in dental office

Antisepsis – the complex measures aiming at prevention of growth and development of
microorganisms
Regular cleaning of dental office is necessary. It is necessary to process all horizontal
surfaces with antiseptic solution at the beginning of the working day (before the first patient), after
each patient and after the end of the working day. At the end of each working floors are washed.
The cleanliness of the instruments in the clinic as a protection not only to the patients
(prevent transmission of germs from one patient to another), protection to the dentists and his
clinical staff.
There are 3 stages of sterilisation
1. Desinfection means treating instruments with disinfecting liquids which kill microorganisms but
spores still remain.
2. Mechanical treatment means cleaning instruments with brushes. Debris, chemical and dental
materials are removed.
3. Sterilization means killing all living organisms (bacteria, fungi, virus, spores and other
microorganisms) for the purpose of preventing diseases.
1. Desinfection
Wash all instruments under running water with brushes
Then instruments are immersed in disinfectant solution and the exposure time is waited.
Another method of disinfection is disinfection in ultrasonic cleaner. Take then into
Ultrasonic cleaner

Ultrasonic cleaner

Functions and directions for use

 Used along with a soapy cleaner
 Used sound waves to reduce bioburden and debris from instruments prior to sterilisation
 Follow manufacturer's instructions for solution types and length of time needed for cleaning
Examples of disinfectants:
1. Mistral,
2. OptiMax.

1. Mistral
Mistral contains 7.5% N, Nbis (3-aminopropyl)dodecylamine as an active ingredient, as
well as auxiliary components: dye, fragrance and water.
It has antimicrobial activity against gram-negative and gram-positive bacteria (including
Mycobacterium tuberculosis, especially dangerous pathogens infections-plague, cholera), viruses
(enterovirus infections; enteral and parenteral hepatitis, HIV, influenza, adenoviruses, etc.,
pathogens of acute respiratory viral infection, herpes, cytomegaly), fungi of the genus Candida,
dermatophytes, mold mushrooms, as well as detergent properties.

Solution preparation
 Disinfection by immersion in disinfectant solution and waiting for exposure time.

Temperature
Concentration of
Steps of Desinfection of disinfectant Exposure time (minutes)
disinfectant solution (%)
solution
Soaking of instruments at 3,0 90
their Not less than
full immersion in 4,0 18 degrees 30
disinfectant solution. 4,5 15
Washing of each 3,0
instrument in the same Not less than
4,0 0,5
solution 18 degrees
4,5
Rinsing with water arbitrary 5-10

Disinfection in ultrasonic cleaner

Temperature
Concentration of
Steps of Desinfection of disinfectant Exposure time (minutes)
disinfectant solution (%)
solution
Ultrasonic cleaner
3,0 40 degrees 15-20

Rinsing with water arbitrary 3

2. OptiMax
OptiMax contains N, N-bis(3-aminopropyl) dodecylamine-5 %, as well as functional
additives, including surfactant, corrosion inhibitor, water conditioner, dye and deionized drinking
water.
 It has antimicrobial activity against gram-negative and gram-positive bacteria (including
pathogens of tuberculosis, nosocomial and anaerobic infections), pathogenic (genus Candida and
Trichophyton) and mold fungi, viruses (Coxsackie, esno, polio, enteral, parenteral transmission of
hepatitis A, b, C, etc., HIV, SARS, influenza, herpes, adenoviruses, etc.), has properties against
pathogens of parasitic diseases (cysts and oocysts of protozoa, eggs and larvae of helminths).
Solution preparation

Disinfection by immersion in disinfectant solution and waiting for exposure time.

Temperature
Concentration of
Steps of Desinfection of disinfectant Exposure time (minutes)
disinfectant solution (%)
solution
Soaking of instruments at 1,0 60
their Not less than
full immersion in 2,0 18 degrees 30
disinfectant solution. 3,0 15
Washing of each 1,0
instrument in the same Not less than
2,0 0,5-1
solution 18 degrees
3,0
Rinsing with water arbitrary 3

Disinfection in ultrasonic cleaner

Temperature
Concentration of
Steps of Desinfection of disinfectant Exposure time (minutes)
disinfectant solution (%)
solution
Ultrasonic cleaner
1,0 40 degrees 15

Rinsing with water arbitrary 3

2. Mechanical treatment
Wash all instruments under running water with brushes once more
3. Sterilization
 • Boiling
• Steam under pressure (autoclave)
• Hot and dry air heat sterilisation
• Chemical (cold)
• Ultrasonic cleaner
• Assistina (for handpieces)

Name
Assistina

Function(s) and directions for use

 Uses air to run cleaning fluid solution and oil through handpieces
 Used to expel debris from handpieces
 Plastic c over handpiece attachment is used to reduce aerosol
 Follow manufacturer's instructions for use

Autoclave: functions and directions for use

• It uses steam under high pressure to achieve sterilization.

• Follow manufacturer’s directions.
• Pack instruments in Sterilisation pouch before autoclaving.

Modes: temperature 141 degrees, pressure 2.8 bar, time 3 minutes;

temperature 134 degrees, pressure 2 bar, time 5 minutes;
temperature 126 degrees, pressure 1 bar, time 10 minutes;
temperature 132 degrees, pressure 2 atmosphere, time 20 minutes;
temperature 120 degrees, pressure 1.1 atmosphere, time 45 minutes (rubber products).
Instruments from corrosion-resistant metals, glass, textile materials, rubber, latex: operational linen,
dressing material, laboratory ware, syringes marked 200 degrees, surgical instruments, instrument
parts, gloves, catheters, probes, drainage tubes.

Name
Sterilisation pouch

Functions and features

 Used to wrap instruments prior to sterilisation
 Aids in organisation of instruments
 One side may be transparent to allow for viewing of the pouch contents
 Coloured markings indicate that a certain temperature has been reached during the
sterilisation cycle
 Instruments will remain sterile in pouch until it is punctured or opened

Hot and dry air heat sterilisation

Modes: temperature 200 degrees, 30 minutes;

temperature 180 degrees 60 minutes;
temperature 160 degrees 120 minutes (time is counted from the moment when the temperature in
the chamber).

Instruments which are made of glass, metal, silicone rubber: medical instruments, instrument parts,
needles, syringes marked 300 degrees, laboratory glassware. Dry products are laid out on the grid.
Medical sister is dressed as an surgery one (sterile coat, cap, mask, gloves).

Quality control of sterilization

Physical method
The method involves measuring temperature, pressure and time.
Temperature control is carried out with the help of maximum thermometers. Range of
measurements from 0 to 150°C for steam sterilizers, from 0 to 200 ° C for air sterilizers.
Packaged thermometers are placed in control points. At the end of the sterilization cycle the
readings of thermometers are recorded, which are compared with the regulated temperature.
Sterilization time is carried out with a mechanical stopwatch or wrist mechanical watch.
The pressure in the steam sterilizer is measured by a pressure and vacuum gauge. Measuring range
1 to 5 kgf/cm2.
Detection of unsatisfactory results indicates possible violations: sterilization, proper loading or
serviceability of the device.
Chemical method
Chemical control is carried out with the help of chemical tests and thermal indicators.
Chemicals are used, sometimes in a mixture with an organic dye that changes its aggregate state and
color at a certain temperature.
Packaged chemical tests are numbered and located in steam and air sterilizers.
Usually indicator connections are sealed in glass tubes. With uniform melting and changing the
color of the test result is considered satisfactory.
To control the operation of steam sterilizers used substances, which melting point corresponds to
the temperature conditions of the device:
— Aminopyrine (white crystalline powder or crystals with no odor), temperature range melting
point 104— 107°C.
- Antipyrine (white crystalline powder or colorless crystals, odorless), 108-111°C.
- Resorcin (white or with a slight yellowish tinge crystalline powder with a weak smell), 105-110°.
- Benzoic acid (colorless needle crystals or white crystalline powder), 114-120°C.-D (+)
- Mannose (colorless crystals in the form of rhombic prisms), 127-131 °C.
- Nicotinamide (white fine crystalline powder with a slight odor), 125-131 °C.
Temperature control of air sterilizers is carried out by tests with other chemical substance:
- Levomitsetin (white or yellowish-greenish tinge crystalline powder), interval melting point 141-
146°C.
- Tartaric acid (colorless crystals), 168-169°C.-Hydroquinone (colorless or light gray silvery
crystals), 164-170°C.
- Thiourea (shiny crystals), 165-171°C.
The detection is not fused test indicates non-observance of temperature mode settings sterilizations.
Sterilization is repeated with the laying of new chemical tests. When unsatisfactory result is
repeated the sterilizer is no longer used. Conduct a thorough check its condition with the control of
measuring equipment.
Bacteriological method
The method is designed to control the operation of sterilizers using biotests. Bioassays represent
spores of bacterial cultures placed in glass tubes or cups from aluminum foil.
Use the test-culture In ECM-718 and strain C. Biotests are preparing bacteriological laboratories
according to the official methodology. In cases of unsatisfactory results (crop growth) the
parameters of the sterilization cycle are analyzed.
Additionally, control of the sterility of the washes from the sterilized can be applied tool's.
The most frequent causes of negative results of sterilization monitoring:
- malfunction of equipment and instrumentation;
- incomplete removal of air from the working chamber of the steam sterilizer;
— overloading and incorrect loading of sterilization camera;
- failure to comply with sterilization parameters;
— use of ad-hoc packaging material;
- violation of the ventilation mode of the steam sterilizer;
- use in chemical sterilization of substances after long-term storage without control
the content of the active principle.

Task:

1. Study the educational material Practical class №4 presented in electronic form in EIEE
(ЭИОС).
2. Start a separate notebook on discipline "Dentistry (Pre-clinical course)". In this notebook,
summary should be written on the topic of each practical class performed using Distance Learning
Technologies (DLT). Summary is written by hand with the topic and date of the practical class. To
write a summary of the educational material (2-5 pages), you have to answer the questions and
complete the following tasks on the topic of the practical class in writing form.
Questions and Tasks.
1. Give definitions of asepsis, antisepsis, disinfection and sterilization.
2. List the stages of sterilization. Write the goal for each stage.
3. What is hot and dry sterilization? Which instruments and materials can be
sterilized in it? Give parameters of hot and dry sterilization (temperature and time).
4. What is sterilization in autoclave? Which instruments and materials can be
sterilized in it? Give parameters of sterilization in autoclave (temperature, pressure and
time).
5. List all stages of hot and dry sterilization (starting from disinfection and
finishing by sterilization).
6. List all stages of sterilization in autoclave (starting from disinfection and
finishing by sterilization).
7. What is Assistina?
8. Sterilization of dental handpieces.
9. What should I do before I start working with dental equipment?
10. What needs to be done after receiving each patient?
11. What needs to be done at the end of the day?
12. What are the requirements for medical clothing and protective equipment?
13. List the main points of safety rules.
14. List the main emergency conditions arising from non-compliance with safety
practices in dental practice.

3. Solve the Test 4 of Practical class №4 presented in electronic form in EIEE (ЭИОС).