Principals and Techniques of

Sterilization

Lokender Yadav
Manager Talent Development
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Introduction
One of the most important responsibilities of the dental assistant is to process
contaminated instruments for reuse.
Instrument processing involves much more than sterilization.
Sterilization is a process intended to kill all microorganisms and is the highest level of
microbial destruction.

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Table 21-1 Seven Steps of Instrument Processing.

Table 21-1
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Classification of Instruments and Equipment
 Instruments and equipment are divided into three classifications:

• Critical
• Semicritical
• Noncritical
 The classifications are used to determine the minimal type of posttreatment
processing.

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Critical Instruments
 Critical instruments must be heat sterilized before reuse. Critical items are
surgical and other instruments used to penetrate soft tissue or bone; examples of
critical instruments include forceps, scalpels, bone chisels, scalers, and burs.

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Semicritical Instruments
 Semicritical instruments are those that come in contact with the oral tissues but do
not penetrate soft tissue or bone; examples include plastic-handled brushes, high
volume oral evacuator (HVE) tips, and amalgam carriers.
 Semicritical instruments should be heat sterilized before reuse. If this is not
possible (because the instrument will be damaged by heat), the instrument should
receive, at a minimum, high-level disinfection.

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Noncritical Items
 Noncritical items should be processed with an intermediate or low-level disinfectant
after each patient use.
 Noncritical clinical items are devices such as the position indicator device (PID) of
the x-ray unit tube head or the lead apron that comes into contact only with intact
skin.

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Instrument Processing Area
 The instrument processing area, or sterilization area, should
be centrally located in the dental office.
 The “ideal” instrument processing area should be dedicated
only to instrument processing.
 It should have good air circulation to control the heat generated
by the sterilizers. The size of the area should accommodate all
the equipment and supplies necessary for instrument
processing.
 There should be a deep sink with hands-free controls for
instrument rinsing.

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Instrument Processing Area cont’d

 The flooring should be an uncarpeted seamless hard surface.

 The size, shape, and accessories of the instrument processing area will vary from one
dental office to another.

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Basic Principles for Work Flow Pattern

 Processing instruments should proceed in a single loop, from

dirty through clean to sterile, without ever doubling back.
 If the instrument processing area is small, you can use signs to
separate the contaminated and clean areas.
 This method works well to prevent mixing of contaminated and
sterile items in a small sterilization area.

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Fig. 21-2 A, Linear flow pattern. B,“U” shaped instrument processing area.

Fig. 21-2
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Contaminated Area
 All soiled instruments are brought into the contaminated area.
 Any disposable items not already discarded in the treatment
room are disposed of as contaminated waste.
 The contaminated area contains clean protective eyewear and
utility gloves, counter space, a sink, a waste disposal container,
holding solution, ultrasonic cleaner, eyewash station, and
supplies for wrapping instruments before sterilization.
 Note: Soiled and clean instruments are never stored in the same
cabinet.

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Instrument Processing Procedures
 Holding solution
• If the instruments cannot be cleaned immediately after the procedure, they should be
placed in a holding solution to prevent the drying of blood and debris on the instruments.

 Precleaning instruments
• Hand scrubbing
• Ultrasonic cleaning
• Instrument washing machines

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Ultrasonic Cleaning
 Used to loosen and remove debris from instruments and reduce
the potential of hand injuries from cuts and punctures during
the cleaning process.
 Puncture-resistant utility gloves, a mask, protective eyewear,
and a protective gown should always be worn when using the
ultrasonic cleaner.
 The ultrasonic cleaner works by producing sound waves, which
are beyond the range of human hearing.
 The time may vary from 5 to 15 minutes, depending on the
amount and type of material on the instruments, and the
efficiency of the ultrasonic unit.

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Ultrasonic Cleaning Solutions
 Use ONLY the ultrasonic solutions that are specially
formulated for use in the ultrasonic cleaner.
 DO NOT use other chemicals such as plain disinfectants in the
ultrasonic cleaner.
 Specific ultrasonic solutions are available that remove difficult
materials, such as cements, tartar, stains, plaster, and alginate.
 The ultrasonic cleaning unit should be labeled with both a
chemical label and a biohazard label because it contains a
chemical and contaminated instruments.

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Testing the Ultrasonic Cleaner
 Hold a 5-inch x 5-inch sheet of lightweight aluminum foil
vertically (like a curtain) half-submerged in the (fresh unused)
solution.
 Run the unit for 20 seconds, and then hold the foil up toward
the light.
 The surfaces that were submerged into the solution should be
evenly marked with a tiny pebbling effect over the entire
surface.
 An area on the foil that is greater than 1/2 inch without pebbling
indicates that there is a problem with the unit and it needs
servicing by the manufacturer.

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Automated Instrument Washers / Disinfectors

 Automated instrument washers/disinfectors look and work

very much like a household dishwasher.
 They must be approved by the U.S. Food and Drug
Administration (FDA) for use with dental instruments.
 These units use a combination of very hot water recirculation
and detergents to remove organic material, and then
instruments are automatically dried.
 They have a disinfecting cycle that subjects the instruments to
a level of heat that kills most vegetative microorganisms.
 Instruments processed in the automatic instrument
washers/disinfectors must be wrapped and sterilized before
use on a patient.

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Drying, Lubrication, and Corrosion Control

 Instruments and burs made of carbon steel can rust during steam
sterilization.
 Rust inhibitors are available as a spray or dip solution and help
reduce rust and corrosion.
 An alternative to rust inhibitors is to thoroughly dry the
instrument and use dry heat or unsaturated chemical vapor
sterilization, which do not cause rusting.
 Hinged instruments may need to be lubricated to maintain proper
opening.

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Packaging Instruments

 Before sterilization, the instruments must be wrapped or

packaged to protect them from becoming contaminated after
sterilization.
 When instruments are sterilized without being packaged, they are
immediately exposed to the environment as soon as the sterilizer
door is opened.
 An additional advantage to packaging instruments is that they can
be packaged into special setups (e.g., crown and bridge,
amalgam, composite).

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Packaging Materials

 Sterilization packaging materials and cassettes are medical

devices and therefore must be approved by the FDA.
 Use only products and materials that are labeled as sterilization
packaging.
 There are specific types of packaging material for each method of
sterilization.
 Never use safety pins, staples, paper clips, or any other sharp
objects that could penetrate the packaging material.

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Sterilization Monitoring
 It is critical that dental instruments are properly sterilized.
 There are three forms of sterilization monitoring:
• Chemical
• Physical monitoring
• Biologic

 All three processes are unique, have different functions, and

must be used consistently to assure sterility.

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Chemical Monitoring
 Involves the use of heat-sensitive chemical that changes color
when they are exposed to certain conditions.
 The two types of chemical indicators are:
• Process indicators are placed on the outside of the instrument packages before
sterilization. They respond to heat only.
• Process integrators are placed inside instrument packages, and they respond to a
combination of steam and temperature and time.

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Chemical Monitoring cont’d

 Process indicators and integrators provide immediate, visual control of sterilizing

conditions, but they do not indicate sterility and are not a replacement for biologic
monitoring.

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A, Unprocessed instruments. B, Wrapped instruments following processing.
Note the color change in the tape.

Fig. 21-12
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The process integrator is placed inside the instrument package

Fig. 21-13
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Physical Monitoring

 Involves physically looking at the gauges and

readings on the sterilizer and recording the
temperatures, pressure, and exposure time.
 Although correct readings do not guarantee
sterilization, an incorrect reading gives you the first
signal that something is wrong.
 The temperature recorded is for the chamber, not the
inside of the pack.
 Problems with overloading or improper packaging
would not be detected from the reading on the
gauges.

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Sterilization Failure

 Several things can cause the sterilization process to fail, including

improper instrument cleaning and packaging, as well as
malfunction of the sterilizer.
 A load may fail to become sterilized when there is not direct
contact for the proper length of time between the sterilizing agent
and the items to be sterilized.

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Table 21-4 Causes of Sterilization Failure.

Table 21-4
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Sterilization

 Sterilization destroys all microbial forms, including bacterial

spores.
 Sterile is an absolute term. There is no such thing as “partially
sterile” or “almost sterile.”
 All reusable items that come in contact with the patient’s blood,
saliva, or mucous membranes must be heat-sterilized.
 It is not recommended to use a liquid sterilant on any item that
can withstand heat sterilization or is disposable.

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 Methods of Sterilization
 The three most commonly used forms of heat sterilization in the dental office are:

• Steam sterilization
• Chemical vapor sterilization
• Dry heat sterilization

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Steam Autoclave Sterilization
 Steam sterilization involves heating water to generate steam,
producing a moist heat that rapidly kills microorganisms.
 Manufacturers set their sterilizers (autoclaves) to reach maximum
steam temperatures of approximately 250˚ F (121˚ C) with
pressures of 15 or 30 pounds per square inch.
 A disadvantage of steam sterilization is that the moisture may
cause corrosion on some high-carbon steel instruments.
 Distilled water should be used in autoclaves instead of tap water,
which often contains minerals and impurities. Distilled water can
minimize corrosion and pitting.

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Types of Steam Sterilizers

 All steam sterilizers operate in a similar manner, but different

models and brands have different features.
 There are various sizes of chambers and mechanisms of air
removal, steam generation, drying, temperature displays, and
recording devices.
 Rapid or “flash” sterilization of dental instruments is
accomplished by rapid heat transfer, steam, and unsaturated
chemical vapor.

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Chemical Vapor Sterilization
 Very similar to autoclaving, except a combination of chemicals
(alcohol, formaldehyde, ketone, acetone, and water) is used
instead of water to create a vapor for sterilizing.
 OSHA requires a material safety data sheet (MSDS) on the
chemical vapor solution because of the toxicity of the chemicals it
contains.
 The major advantage of the chemical vapor sterilizer is that it does
not rust, dull, or corrode dry metal instruments.
 A wide range of items can be sterilized routinely without damage.
Other advantages are the short cycle time and having a dry
instrument at the end of the cycle.

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Monitoring Chemical Vapors
 The primary disadvantage is that adequate ventilation is essential
because residual chemical vapors containing formaldehyde and
methyl alcohol can be released when the chamber door is opened
at the end of the cycle.
 These vapors can temporarily leave an unpleasant odor in the area
and may be irritating to the eyes.
 Newer models are equipped with a special filtration device that
further reduces the amount of chemical vapor remaining in the
chamber at the end of the cycle.
 Formaldehyde monitor badges that are worn by the employee
(much like radiation monitoring devices) are available.

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Packaging for Chemical Vapor Sterilization
 Types of wraps include film pouches or paper bags, nylon see-through tubing,
sterilization wraps, and wrapped cassettes.
 Thick or tightly wrapped items require longer exposure.
 Closed containers, such as solid metal trays, capped glass vials, and aluminum foil,
cannot be used in a chemical vapor sterilizer because they prevent the sterilizing
agent from reaching the instruments inside.

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Pressure, Temperature, and Time
 The three major factors in chemical vapor sterilization are:

• Pressure (20 psi)

• Temperature 131˚ C (270˚ F)
• Time (20 to 40 minutes)

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Handpiece Sterilization
 High-speed dental handpieces rotate at speeds up to 400,000 rpm.
 Blood, saliva, and tooth fragments, as well as restorative materials, may get into the
head of the handpiece, where they may be retained and transferred to another patient.
 Therefore, dental handpieces must be properly cleaned and heat-sterilized.

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Flushing of Handpieces

 If debris is not removed before heat sterilization, it will

bake onto the turbine and bearings.
 Flushing the handpiece is the best way to remove debris
from the head of the handpiece.
 Attach a pressurized handpiece cleaner to the intake tube
of the handpiece (where the air passes through) and flush
the head of the handpiece to remove debris.
 Afterward, blow out the handpiece using compressed air to
remove debris before sterilization.
 Coolant water does not run through the turbine chamber,
where debris can collect and compromise handpiece life.

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Sterilizing Handpieces

 Only steam sterilization and chemical vapor sterilizers are

recommended, because handpiece sterilization
temperatures should not exceed 275˚ F (135˚ C).
 Never run a handpiece hot out of the sterilizer, and avoid
rapid cool-downs, such as running the handpiece under
cold water.
 Handpieces use very small metal components; taking them
from very hot to very cold temperatures stresses the metal.
Instead, if handpieces need to be cooled quickly after
sterilization, use an air fan to blow room-temperature air
over it.

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