1. Principles of Sterilization
Navy Reserve Dental Corps
Infection Control Program

2. The complete elimination or destruction of all living organisms
Sterilization
The complete elimination or destruction of all living organisms

3. Categories of Patient Care Items
Critical: Penetrate soft tissue or bone or enter bloodstream or other sterile tissue. Ex: forceps, scalpels, bone chisels, scalers, perio probes
Semi-Critical: Do not penetrate soft tissue or bone but contact mucous membranes or non intact skin. Ex: mirrors, amalgam condensers
Non-Critical: Come into contact with intact skin. Ex: x ray head, blood pressure cuff
According to the CDC dental instruments are classified into three categories depending on the risk of disease transmitting infection.

4. CRITICAL SEMICRITICAL NONCRITICAL
Penetrates soft tissue or bone
Contacts mucous membrane or non intact skin
Contacts intact skin
Sterilization
Sterilization or high level disinfectant. Sterilization is BEST practice
Low to intermediate level disinfection
Surgical instruments, perio scalers, dental burs, perio probes
Mouth mirror, amalgam carrier, dental hand pieces
X ray head / cone, blood pressure cuff, face bow
Sterilization is achieved by steam under pressure, autoclaving, dry heat or chemical vapor. Some items can’t be sterilized. A high –level disinfectant is registered with the EPA.

5. Periodontal Probes are Critical instruments as they penetrate soft tissue MUST be sterilized before use per CDC guidelines

6. Kerr Single Use, Pre Sterilized…Why is it better?
Ready-to-use. Minimizes tray set-up time.
Hygienic. Single-use, eliminates cross-contamination issues.
Convenient. Excellent for routine use, especially during busy surgery times, staff shortages, autoclave breakdowns, home visits and for high-risk patients. PRE -STERILIZED
Time-saving. Reduces time spent sterilizing and handling sharps.
Cost-effective. Increases productivity and reduces inventory.

7. What is wrong with I Paks. They are NOT STERILE
What is wrong with I Paks? They are NOT STERILE! As part of a standard T2 exam dental probe depths need to measured, and the probe is a critical instrument… it MUST be sterile.

8. Processing of Instruments
All critical and semi critical dental instruments that are heat stable should be sterilized after each use by steam under pressure (autoclaving), dry heat or chemical vapor.
Before treatment instruments should be cleaned so that they are free of debris.
Enzymatic and non enzymatic solutions facilitate instrument cleaning.

9. Instrument Processing
A group of activities that when done in the correct sequence, in the right environment, with the correct materials, and using the appropriate procedures, results in the sterilization of instruments.

10. Consider work flow when planning
Proper work flow prevents error
Receive and Clean
Rinse and Pack
Sterilize
Clean, Dry Storage

11. Instrument Processing Area
Use a designated processing area to control quality and ensure safety
Divide the working areas:
Receiving, cleaning, decontamination
Prep and packaging
Sterilization and Monitoring
Storage

12. Cleaning of Instruments
Use appropriate PPE: eyewear, heavy duty utility gloves, gown, face protection
Rinse / ultrasonic and DRY before packaging
Follow manufacturer’s guidelines for use of ultrasonic.
Use the proper amount of solution and proper time
Cover the unit with lid when in use

13. Cleaning of Instruments
Wear Proper PPE. Heavy duty puncture resistant utility gloves
Eyewear, gown and mask
Heavy duty gloves should be worn when handling contaminated instruments.
Instruments should soak in water or disinfectant / detergent as soon as possible after use to prevent drying and caking of debris
Instrument cassettes and mechanical cleaner (ultrasonic device) may be used to reduce direct handling of contaminated instruments

14. Cleaning of Instruments
-Applying rust inhibitors will protect instruments from corrosion that may result from autoclaving.
-Packaging rinsed and dried instruments before sterilization protects them from contamination after they are removed from the sterilizer and during transport chair side or to storage.
-Single use instruments are acceptable for use if used only once and disposed of correctly.

15. Degassing
Degassing is the removal of large air bubbles found in all fresh solution, which act as a barrier to effective cleaning
**Degassing is needed each time new solution is added**
Degas the solution by activating the unit for 15min before you add any items to be cleaned.

16. Preparation and Packaging
Use a container system or wrapping compatible with the type of sterilization process used and that has FDA clearance
ALL instruments that enter the patients mouth should be wrapped
Open instruments at the chair, at time of use.

17. Sterilization HEAT STERILATION:
Recommended for all critical and semi critical items
Must follow the manufacturer’s instructions for cleaning, lubrication, and sterilization to ensure the effectiveness of process
HEAT STERILATION:
Moist Heat- steam under pressure, Autoclaving degrees.
Dry Heat-Static or Forced Air- No corrosion, uses dry heat degrees
Unsaturated Chemical Vapor-uses unsaturated chemical vapors from formaldehyde and alcohol, 273 degrees

18. Steam Sterilization
Gold standard. Dependable, economical, heats rapidly, destroys most resistant bacterial spores in brief exposure
Indicated for heat stable instruments, device
Methods of steam sterilization differ in the mechanism used for air removal from the chamber

19. Air Removal Gravity Displacement Dilution by mass flow
Dilution by pressure pulsing
High-vacuum sterilization
Pressure pulsing with gravity displacement (steam flush-pressure pulse)
The methods of steam sterilization differ in the method that air is removed from the chamber. Here are the different methods.

20. Gravity Displacement Steam is admitted through a control valve
Steam forms stratified layer across the top of chamber
Steam mass displaces air via drain vent
Best for unwrapped or lightly wrapped material

21. Steam-Flush Pressure Pulse
MOST effective air removal, using cycles of pressurization, air evacuation
Air is removed to a predetermined pressure
Steam is admitted
Air is removed my gravity displacement
Chamber is re-pressurized
Chamber air is evacuated
Steam in pack expands, removing all air load

22. Steam Flush Pressure Pulse

23. Air Removal Test First cycle of every day
Indicates good air removal and airtightness
Cannot be performed during regular processing

24. Dry Heat Sterilization
Static Air
Heat coils on bottom or side of sterilizers heat, causing hot air to rise in the chamber
Heat is transferred to the instruments and sterilization occurs after 1-2 hours of consistent heat contact
Forced Air
Circulation of the heat using a fan in the chamber
Transfer of heat to instruments occurs more rapidly
Sterilization time is approximately 12 minutes for wrapped instruments

25. Dry Heat Sterilization
Good heat penetration
Non corrosive
But…diffusion and penetration of heat is slow
Can require an extended time
Requires high temperatures that can damage materials
Oxidation

26. Unsaturated Chemical Vapor
Chemical vapor produced from solution containing formaldehyde, ethanol, or other
Vapors may be removed using a built in purge (older models require ventilation)
Waste liquid is a hazardous waste
Not preferred method

27. More about Autoclaves Water heated to form steam
Moist heat destroys the microorganisms
Air must be removed for the sterilization process to occur
4 steps: Heat Up Cycle, Sterilization Cycle, Depressurization Cycle, Drying Cycle

28. Dental Hand Pieces
DO NOT surface disinfect, use liquid chemical sterilants, or ethylene oxide on hand pieces and other instruments!
Follow the manufacturer’s instructions for cleaning, lubricating, and sterilization

29. Steam Sterilizer Loading Allow for circulation
Dry non porous containers must be positioned so that water will not run out

30. Sterilization Monitors
Physical- cycle time, temperature, pressure
Chemical- heat or chemical sensitive inks that change color when germicidal-related
Biological- bacillus spores that directly measure sterilization
ALL 3 need to be done!!!

31. Physical Monitoring Monitor cycle time, temperature, and pressure
Observe gauges / displays
Review print-out from sterilizer if available
Error message will indicate an important parameter has not been met
Only one part of the monitoring process indicating only the condition in the chamber of the sterilizer
Each time the sterilizer is used the operator needs to check all physical parameters and ensure the machine is being operated properly.

32. Chemical Indicators External Indicator Internal Indicator
Provides visual of sterilization process
Internal Indicator
Visual sterilant penetrated the tray or pack

33. Chemical Indicators
Internal indicators MUST be included inside EACH sterilization package
External Indicators MUST be used IF the internal indicator is not visible
Multiple types of indicators Class I-V for different units
STOP if indicator shows processing failure and DO NOT use instruments, reprocess prior to use

34. Biological Monitors Perform weekly Types:
Steam – Geobacillus stearothermopholis
Dry Heat- B. atrophaeus
Spore Tests are standard and are accepted for assuring sterility. They kill highly resistant micro-organisms, spores.

35. Spore Testing
Only a biologic indicator consisting of resistant spores can measure the microbial killing power of the sterilization process.
IF the spores are killed then all other microorganisms are killed

36. Sterilization Cycle Verification
Verifies process before a sterilizer is first used
Autoclaves should be tested with chemical indicator and biologic indicator prior to:
First use
Relocated (on AT)
After sterilization failure has occurred
After a major repair
RUN 3 CONSECUTIVE CYCLES and TESTS

37. Why do we need to spore test?
Sterilizers fail spore tests for different reasons
Most often cause: operator error
cycle interrupted
incorrect package
overloaded
incorrect time or temp

38. Positive Spore Test Following a single positive biological indicator:
Remove the sterilizer from service and review sterilization procedures, is it operator error
Retest the sterilizer by using biologic, mechanical, and chemical indicators
Make sure to use the same cycle that failed
Repeat the spore test again, if negative the sterilizer may be placed back in service
Best to recall all instruments, not required

39. Positive Spore Test If REPEAT positive test:
- DO NOT USE until it has been inspected or repaired or the exact reason has been determined
- Recall and reprocess all items since the last negative test
After repaired, re-challenge with biological indicator tests in 3 consecutive empty chamber cycles

40. Causes of Sterilization Failures
Overloading- increases heat up time and prohibits agent to completely penetrate the load

41. Causes of Sterilization Failures
Instruments loaded too closely together- agent not able to move about within the unit and may not be able to penetrate all packages
Incorrect packaging materials
Interruption if sterilization cycle
Incorrect operation of the sterilizer

42. In the Field Generators may fail and power supply to sterilizer may be interrupted. Reprocess these instruments! Watch your unit!

43. Documentation Monitoring Log
Sterilizer identification number (serial # and model)
Load number
Duration and temperature of cycle
Contents of load
Record if charts, readings, printouts
Biological Monitoring
Maintenance Records
MUST keep a log!
Operators signature and name on log

44. Biologic Monitoring Options
Multiple options: on site, mail in, university
Must have a control outside the sterilizer
Incubate both the control and the test vial
Should have bacterial growth in control sample
If the Control has no growth test is NOT conclusive and must be re-done

45. Dispose of Spore Test Must be no active spores
Autoclave the control or failed vials

46. ATTEST 3M Attest 390 Rapid Auto Reader Results in 3 hours
3M Attest 490 is a one hour auto reader, works with both Gravity and Pre-Vac Sterilizers
Quick results, useful in isolated settings
The auto-reader allows onsite quick results

47. 3M ATTEST Auto-reader Expensive Read by operator No third party verification

48. Crosstex Confirm10 In office results 10 hours Easy to use and read tests

49. ConFirm Monitoring System, Crosstex
Mail In service
Test results in 24 hours
Benefit- third party verification of test results
Economical

50. Other options www.autoclavespore testing.com www.microtestlabs.com
MANY more options, not all will work in our unique setting. Time is crucial in 2 week mission.

51. Some other reasons tests fail
Inadequate cleaning of instruments- if there is caked on debris it won’t be sterile!
Improper packing- don’t overload instruments, they should be able to lay flat within the cassette

52. More Reasons Cycles Can Fail
Processing Instruments in a cold sterilizer- a cold sterilizer takes much longer to come up to temperature, since it must heat the chamber and its contents. Run an empty chamber first before the first load is processed
Selecting the Wrong Cycle-some units will have manual and automatic settings. ALWAYS select the longer cycle when sterilizing mixed loads

53. Reasons Cycles Fail
Aborting a Cycle: NEVER abort a cycle so that instruments may be used more quickly. NEVER open during a cycle to add more instruments. Even though it may save time DO NOT stop cycle before its complete, including the drying time.
If you need to add more instruments, restart the cycle

54. Storage of Sterile Items
Well ventilated to protect against dust and moisture
Consistent temperature and humidity
Packaging should include load number, sterilization date
Shelf Life: can be time related or event related
Depends on type of packaging

55. Common Problems White Build Up on Instruments Damage to Plastics
Thoroughly dry before packaging and sterilizing
Damage to Plastics
Monitor temperature
Avoid flash cycles
Ensure plastics are heat stable to temperature used in sterilizer
Wet Packs
Do not overload sterilizer
Allow full drying cycle
Purchase sterilizer with vacuum drying cycle

56. Residual Debris on Instruments after cleaning
Debride instruments at time of use (NOT with gauze and your hand…washer or utility gloves and brush)
Use enzymatic pre-soak or pre-spray for organic materials
Corrosion of surgical hand pieces
Internal components and nitrogen-driven hand pieces are prone to corrosion
Stand the hand pieces on end or at an angle to sterilize
Allow to thoroughly dry before removing from sterilizer

57. Dental Burs
Cleaning and sterilization do not reliably remove all organisms from burs
Ideal practice is to move towards pre-sterilized single use disposable burs.

58. Culture
All Reserve Dental Corps Officers and Enlisted members should know how to operate the sterilizer
All should know how to tell if the instruments have been effectively sterilized
Best practice to open sterile wraps in front of patient, builds trust
All member should call a STOP if they suspect a breach in sterilization

59. Duty of the Health Care Team
Chain of Command, who can step up if they think instruments are not being properly sterilized…
ALL HANDS!!!!
All patients and instruments must be treated with universal precautions no matter where we are, or who we are working on!!!

60. Resources OSAP www.osap.org
From Policy to Practice: OSAP’s Interactive Guide to the CDC Guidelines
CDC Guidelines for Infection Control in the Dental Health Care Setting 2003