Sterilization and disinfection

of dental metallic biomaterials and instruments

Course name:- Applications of metals and alloys

in dentistry
Course code:- 09708

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 Introduction
• Microorganisms are ubiquitous.
• Since pathogenic microorganisms cause
contamination, infection and decay, it
becomes necessary to remove or destroy
them from materials and areas.
• This is the objective of infection control, and
sterilization.

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History of sterilization and disinfection

In 460-377 BC, Hippocrates of Cos

was the first to separate medicine
from philosophy, and advocated
irrigation of wounds with wine or
boiled water, foreshadowing asepsis.

In 1847, Ignaz Semmelweis (an

Hungarian obstetrician) advocated
the value of hand washing and
fingernail scrubbing.

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 In 1862, Louis Pasteur (French
chemist and microbiologist)
publishes his findings on how germs
cause disease, which he later uses to
develop the pasteurization process.

in 1876, Charles Chamberland,

developed the first pressure steam
sterilizer, or autoclave.

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 In 1881, Robert Koch and his associates
research on the disinfecting properties of
steam and hot air mark the beginning of
the science of disinfection and
sterilization. They devised the first non
pressure flowing steam sterilizer.

In 1886, Gustav Neuber introduced

mercury chloride to clean his apron. He
advocated scrubbing the furniture with
disinfectant and sterilizing everything in
contact with the wounds.

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 In the early 1900’s, Aesculap
manufactured chrome-plated containers
for safe transport of sterile instruments
after the first stainless steel ones,
responding to the needs of the military
hospitals and aid stations.

In 1956, J.J. Perkins published the

principles and methods of sterilization
and disinfection in health care sciences.
In 1968, Earle H proposed how an object
should be disinfected or sterilized based
on its intended use.

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 Definitions and terminology in
sterilization and disinfection
• Infection control; Also called “exposure control plan”
by OSHA is a required office program that is designed
to protect personnel against risks of exposure to
infection.
• Sterilization; a process that destroys all viable
microbes including viruses and endospores;
microbicidal.
• Sterile; Free from all living microorganisms.

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• Disinfection: a process of removing or killing most, but not
all, viable organisms by chemical or physical methods.

• Disinfectant: A chemical agent used on inanimate objects

to destroy microorganisms, but not necessarily all
microbial forms.
• Sepsis; bacterial contamination.
• Asepsis; absence of significant contamination
• Bactericidal (microbicidal); -cidal means kill.
• Bacteriostatic (micro biostatic); -static means inhibition of
growth and multiplication.
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 Aim of sterilization and disinfection

• Asepsis is the practice to reduce or eliminate

contaminants (such as bacteria, viruses, fungi, and
parasites) from entering the operative field in
dentistry, surgery and medicine to prevent infection.

• Ideally, a field is "sterile" free of contaminants a

situation that is difficult to attain. However, the goal
is elimination of infection, rather than sterility.

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How sterilization and disinfectants works ?.

• (1) Cell wall maintains the integrity of cell, when disrupted,

cannot prevent cell from bursting due to osmotic effects.
• (2) Cytoplasmic membrane contains cytoplasm and controls
passage of chemicals into and out of cell, when damaged,
cellular contents leak out.
• (3) Viral envelope responsible for attachment of virus to target
cell, damage to envelope interrupts viral replication, so non
enveloped viruses have greater tolerance of harsh conditions.
• (4) Protein coagulation and substrate competition are also
reported with chemical disinfectants.

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 Microorganisms and their resistance to disinfection and
sterilization and the level of disinfection or sterilization needed

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 Dental metallic biomaterials and
instruments
 Dental metallic  Instruments
biomaterials
• Are used to replace or • Are used to examine,
restore function to a restore, extract teeth,
body tissue and remain and manipulate tissues.
continuously or
intermittently in contact
with body fluids.
Both, must be highly sterile for successful treatment
outcomes, patient safety, and not to transmit diseases
between patients.
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(i) Dental metallic biomaterials
• Fabricated from high noble, noble, and base
metal alloys represent the most highly used class
of biomaterials in dentistry as metals have;
• - High strength
• - High toughness
• - High resistance to fracture
• - High resistance to corrosion and wear.

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• They are used as;
Filling materials
(silver amalgam)
Fixed and
Orthodontic removable
appliances. prosthesis

Bone plates
Implants
bone screws

Scaffolds

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(ii) Dental metallic Instruments
• Fabricated from stainless steel, titanium, and other
metal alloys are used in every fields of dentistry:-
Oral examination
and diagnosis

Oral and
Periodontics maxillofacial
surgery

Fixed and Restorative

removable dentistry and
prosthodontics endodontics
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• These metallic biomaterials and instruments
must be rendered very sterile prior to use for
patient safety and successful treatment
outcomes.

• *Note: Devices must be cleaned prior to disinfection

or sterilization procedures.
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Types of cleaning, disinfection and sterilization
processes
Cleaning Disinfection Sterilization
(1) Manual Cleaning (1) Low level (1) High Temperature -
without use of brushes, or Kills most vegetative Moist heat/steam
specialized tools bacteria, some viruses and - And dry heat
some fungi.
(2) Low Temperature
(2) Intermediate Level
Ozone
(2) Automated Cleaning Kills vegetative bacteria,
using ultrasonic medical viruses, fungi and (3) Chemical
washers mycobacterium. Glutaraldehyde (high
(3) High Level concentration)
Kills all microbial organisms (4) Gas
with potential to render Ethylene Oxide -Hydrogen
the device sterile. peroxide (gas plasma) –
(4) Thermal
Disinfection via thermal (5) Radiation
applications under 100°C. -Gamma, E-beam

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 Dental metallic biomaterials and instruments
are classified into:-
Device Classification Definition Examples

Critical •Introduced directly into dental implants, scaffolds,

blood stream or other bone plates, bone screws,
normally sterile areas of extraction forceps, surgical
the body. instruments, periodontal
scalers, surgical burs, and
endodontic instruments.
Semi-Critical •Intact mucous examination instruments,
membranes. operative and orthodontic
•Does not penetrate the instruments, impression
blood stream or normally trays, saliva ejector, water
sterile areas of the body. syringe tips, and removable
and fixed prosthesis.
Non-Critical •Intact skin of patient x-ray tube, head rest,
rubber dam frame,
instrument table, handle of
saliva ejector and suction
and handle of light.
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 Acceptance criteria summary
Device Classification Treatment Options Criteria

Critical (Must be Sterile) Sterilization - Sterilization: SAL – 10-6

Semi-Critical (Sterile or Sterilization - Sterilization: SAL – 10-6 - - -

disinfected) or - Disinfection: 6 log
High Level Disinfection reduction

Non-Critical (Does not Simple cleaning - Sterilization: SAL – 10-3

need to be sterile) or - Cleaning: Removal of
Low level disinfection residuals, visually clean .-
Or - Disinfection: 3-log
Intermediate level reduction
disinfection

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 Methods of sterilization and disinfection

Sterilization Methods Disinfection Methods

 (1) Physical Methods  (1) Physical Methods
• Moist heat in autoclave • Boiling & Pasteurisation
• Dry heat in ovens • UV radiation
• Irradiation  (2) Chemical Agents
• Filtration • Alcohols
• Plasma sterilization • Aldehydes
 (2) Chemical Methods • Halogens
• Ethylene oxide • Phenols
• Glutaraldehyde (high • Surfactants
concentration) • Heavy metals
• Ozone • Dyes and Oxidants
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 I. Sterilization Methods

(1) Physical Methods (2) Chemical Methods

Moist heat in Autoclave Ethylene oxide

Dry heat in ovens Glutaraldehyde (high concentration)

Irradiation Ozone

Filtration

Plasma sterilization

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 Physical Sterilization Methods
1- Moist heat in Autoclave
 Autoclaves use pressurized
steam to destroy Mgs. and are
the most dependable systems.

 Three major factors for

effective autoclave:
• 1. Pressure
• 2. Temperature
• 3. Time
 Higher temperature and
pressure require shorter time
for sterilization.
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• Types: 1) Steam pressure
sterilization (autoclave)
• It works on principle as that of
pressure cooker.

• Time: 15 minutes
• Temperature: 1210 C
• Pressure: 15lbs
• Advantages: rapid and effective.
• Disadvantages: not suitable for
sensitive items, and tends to
rust carbon steel instruments
and burs.
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• 2) Chemical vapor pressure
sterilization (Chemiclave)
• It is similar to steam sterilizer.
• It uses special chemical solution as
formaldyhyde and alcohol.
• Chemical vapor at high temperature
kill the microorganisms by destroying
the vital protein systems
• Temperature:131oC
• pressure: 20lbs.
• Time: 30minutes.
• Advantages: carbon steel, corrosion
sensitive instruments and pliers are
sterilized without rust or corrosion.

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• Advantages and disadvantages of autoclaves
Advantages Disadvantages

1. Economical 1. Items sensitive to the elevated

2. Good penetration temperature will be damaged.
3. Short cycle time 2. Vapor odor of chemiclave is
4. Easily monitored offensive, requires aeration.
5. No special chemicals or exhaust 2. Heavy cloth wrappings of
required surgical instruments may not be
penetrated to provide
sterilization.

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 Physical Sterilization Methods
2- Dry heat in ovens
 It’s the most widely used mode
of sterilization.

 Temp.:- 160°C for 1-2 hr.

 Uses :- Glasswares like glass

syringes, flasks, pipettes & test
tubes.
• - Surgical instruments like
scalpels, scissors, forceps etc..
• - Chemicals such as liquid
paraffin, fats, greases, dusting
powder etc.

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Advantage: Disadvantage :
1. Economical. 1. Hot air is bad conductor of heat
2. Does not rust metals hence it has less penetrating power.
3. Easily monitored . 2. Materials to be sterilized should be
4. Used for anhydrous oils & powder. perfectly dry.
3. Rubber materials (except silicone
rubber) will not withstand the
temperature.
4. Allowed to cool for 2 hrs before
opening the doors.

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 Physical Sterilization Methods
3- Irradiation

 1) Non-ionising radiation:
• Uses longer wavelength and lower energy and hence
lose the ability to penetrate substances, and can only
be used for sterilizing surfaces.
• Eg. infrared radiation is used for rapid mass
sterilization of prepacked items eg. syringes,
catheters.
• UV radiation is used for disinfecting enclosed areas
like operation theaters, laboratories.

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2) Ionising radiation:
• Uses short wavelength, high-intensity radiation with
high penetrative power to destroy microorganisms.
• This radiation can come in the form of gamma or X-
rays that react with DNA resulting in a damaged cell.
• Since there is no increase in the temperature, it is
also known as COLD STERILIZATION.
• It is used for sterilizing plastics, swabs, metal devices
etc.

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 Gamma radiation
• A form of pure energy that is generally characterized by its
deep penetration and low dose rates.
• Gamma radiation is a penetrating sterilant even with high-
density products.
• It effectively kills microorganisms throughout by attacking the
DNA molecule.
• Benefits of gamma radiation include: 1. precise dosing 2. rapid
processing 3. uniform dose distribution 4. system flexibility 5.
the immediate availability of product after processing.

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 Physical Sterilization Methods
4- Filtration sterilization
• Filtration process does not destroy but removes the
microorganisms. It is used for sterilization of liquids
and gases as it is capable of preventing the passage
of both viable and non viable particles. It is also used
for sterility testing.

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 Physical Sterilization Methods
(5) Plasma sterilization
• Plasma is basically an ionized
gas. When an electric field is
applied, it gets ionized into
electrons and ions.

• Their combined photolytic,

chemical and electric action
efficiently kills most micro-
organisms.

• It is extremely penetrative and

could be used for sensitive
equipment like handpieces.

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 Chemical Sterilization Methods
(1) Ethylene oxide

• Highly inflammable and in

concentration more than
3% highly explosive.
• Mix with carbon dioxide or
nitrogen serve to eliminate
its explosive tendency.

• It is extremely penetrative.
• Effective against all types of
micro-organisms including
viruses and spores.
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 Chemical Sterilization Methods
(2) Glutaraldehyde/Cidex (high concentration)
• High level disinfectant.
• Especially active against
tubercle bacilli, fungi and
viruses.
• Less toxic than
formaldehyde.
• Can be safely used to treat
corrugated rubber
anaesthetic tubes, face
masks, and metal
instruments.
• Exposure time: > 10hrs.
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 Chemical Sterilization Methods
(3) Ozone sterilization
• Ozone is formed by applying
electrical energy to the oxygen
molecule, which splits in half, into
singlets of O. Those single O
atoms attach to O2 for a very
short time period, becoming O3
(aggressive oxidating
antimicrobial agent).
• Ozone is suitable for many heat
sensitive and moisture sensitive
medical devices. It also is
compatible with stainless steel
and other metallic instruments.

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 II. Disinfection Methods

(1) Physical Methods

Boiling &
Pasteurisation

UV radiation
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 Physical Disinfection Methods
(1) Boiling & Pasteurisation

• Boiling is a very simple method of disinfection.

• Heating water to a high temperature, 100°C, kills
most of the pathogenic organisms.
• In order for boiling to be most effective, the water
must boil for at least 20 minutes.
• Cutting instruments should not be disinfected by
boiling as they loose its sharpness.
• Pasteurisation is used for disinfection of milk and
beverages.
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 Physical Disinfection Methods
(2) Ultraviolet Irradiation

• The optimum wavelength for UV sterilization

is 260 nm. The UV light could alter the DNA of
the pathogens, but not effective against RNA
viruses like HIV.

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 Chemical Disinfection Methods
(1) Alcohols
• Two types available; isopropyl
alcohol and 70% ethyl alcohol.

• Mechanism of action:
Denaturation of Proteins.

• Ethyl alcohol is active against the

fungal spores and is used to treat
cabinets and incubators and is
suitable for skin preparation
before venipuncture.
• Disadvantage; inflammable,
mucous membrane irritation, and
promotes rusting.
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 Chemical Disinfection Methods
(2) Aldehydes
• (I) Formaldehyde (formalin);
• It acts as a bactericidal and
sporicidal. It is active against
Gram -ve bacteria, spores, viruses
(HB, HIV) & fungi.
• Aqueous soultion: is used to clean
metal instruments and
endoscopes.
• While gaseous form: is used in
fumigation of wards/ corridors/
ICU’s.
• Formaldehydes have pungent
odor and irritating effect on skin
and mucous membranes.

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• (II) Glutaraldehyde /Cidex
( 2% alkaline NaHCO3)
• Glutaraldehyde in high
concentration is used as
chemical sterilant so
previously mentioned under
the class of chemical
sterilants.
• Decreased concentration of
glutaraldehydes leads to
reduced efficiency so, could
be considered as a chemical
disinfectant also.
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 Chemical Disinfection Methods
(3) Halogens
• A) Chlorine compounds:
• A bleaching powder or
hypochlorite solution, mostly
used disinfectant for HIV infected
material.
• It is used for surface material
and instruments disinfection (in
concentration of 0.05 or 0.5%).
• It should be prepared daily
because of the instability of
sodium hypochlorite solution.
• It is active against bacteria,
spores, fungi and viruses (HB,
HIV).
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• B) Iodophors & Iodine
• They are active against
bacteria, spores, some
viruses and fungi.

• Suitable for skin

preparation, as
mouthwashes and as a
surgical scrub.

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 Chemical Disinfection Methods
(4) Phenols
 Eg. Cresol (Lysol)
 Chlorhexidine(Savlon)
 Chloroxylenol (Dettol).

• Phenols acts by cell membrane

damage thus releasing cell
contents and causing lysis.

• Used for decontamination of

the hospital environment,
including laboratory surfaces,
and noncritical medical items.

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 Chemical Disinfection Methods
(5) Hydrogen Peroxide
• H2O2 acts on the microorganisms
through its release of nascent
oxygen.
• Hydrogen peroxide produces
hydroxyl-free radical that
damages proteins and DNA.

• Applications; It is used at 6%
concentration to decontaminate
the instruments and equipments.
• 3% H2o2 solution is used for skin
disinfection and deodorising
wounds and ulcers.

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 Physical Disinfection Methods
(6) Surfactants
• E.g. quaternary
compounds.
• Surface active agents.
• Substances which alter
energy relationships at
interfaces, producing a
reduction of surface
tension.

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 Chemical Disinfection Methods
(7) Heavy metal salts

• Salts of heavy metals

have toxic effect on
bacteria.
• The salts of copper,
silver and mercury are
used as disinfectants.

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 Chemical Disinfection Methods
(7) Dyes and Oxidants

• Acridine and aniline dyes are bactericidal because

of their interaction with bacterial nucleic acids.
• Aniline dyes includes; crystal violet, malachite
green and brilliant green.
• Acridine dyes includes; acriflavine and
aminacrine.
• They are more effective against gram positive
bacteria than gram negative bacteria and are
more bacteriostatic in action.
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• The recommended sterilization and
disinfection methods for metallic dental
biomaterials and instruments

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 Implants

• Pre sterilized with Gamma radiation.

• In case the implants needs to be re-sterilized
conventional sterilization techniques are not satisfactory.
• Steam sterilization and dry heat sterilization should not
be used as they results in contamination of surfaces with
organic substances.
• Radio frequency glow discharge technique (RFGDT) or
Plasma cleaning could be used.
• The material to be cleaned is bombarded by high
energetic ions formed in gas plasma in a vacuum
chamber.
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 Sutures

• Sutures are pre sterilized by gamma radiation.

• Sutures are re- sterilized by two recommend
methods:- 1). Soak for a full 10 minutes completely
immersed in povidone iodine 10% solution, then
rinse in sterile saline/water. 2). Ethylene oxide gas
sterilization.

• Sterilizing/disinfecting by other methods

(autoclaving, boiling, alcohol-soaking) are not
recommended.
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 Bone plates and bone screws

• Metallic bone plates, bone screws, and

scaffolds usually receive similar sterilization
methods to that of implants and sutures. After
sterilization they are stored packaged properly
till use.

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 Dental amalgam alloys/ fixed and removable prosthodontics

• Dental amalgam alloys are usually sterilized before

marketing. It is packaged and sterilized using gamma
irridation or ethylene oxide to avoid loss of
properties.
• Fixed and removable prosthodontics when first
comes from the laboratory they should be sterilized
using steam pressure autoclaves or chemiclaves.

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 Rotaory Instruments - Burs

• Diamond and carbide burs: After use they are

placed in 0.2% gluteraldehyde solution for at
least 10 minutes, then cleaned with a bur
brush or in an ultrasonic bath. Sterilization is
done in an autoclave or dry heat ovens.
• Steel burs: May get damaged by autoclaving.
Can be sterilized by using a chemical vapor
sterilizer or glass bead sterilizer at 2300C for
20-30 seconds.
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 Impression trays

 Are sterilized as follow:

• metallic – autoclave
• plastic – ethylene oxide

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Dental hand piece

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 Metallic endodontic instruments

• Files , spreaders, pluggers, post and core kit,

endodontic explorers, and apex locators are
best sterilized using steam pressure autoclave
after proper cleaning.

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 Periodontal instruments

• Periodontal instruments are classified into;

• Sharp instruments as; knives, scissors, files, tissue
holding forceps.
• blunt instruments as; mouth mirrors, tweezers, artery
forceps, suture holding forceps, periosteal elevator.

• Sharp instruments are ideally sterilized by:

conventional hot air oven. But not sterilized by;
boiling, autoclave ,or 2% glutaraldehyde.
• Blunt instruments are sterilized by autoclave.
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 Ultrasonic scalers
• Usually soaked in a container containing 70% isopropyl
alcohol for removal of organic debris.
• Then rinsed thoroughly in warm water to remove all
chemicals.
• And replaced into the scaler handpiece that is allowed
operate for 10 seconds at the maximum water flow setting to
flush out any retained chemicals.
• Then dried completely with air syringe and packaged.
• Ethylene oxide is the preferred sterilization method for
ultrasonic scallers. Dry heat and chemical vapor methods of
sterilization are considered ineffective methods with risk of
damage.
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 Effect of sterilization and disinfection on
metallic instruments
• Effects differ according to the material of the
instruments and the method of sterilization
used.
• Effects range from no effect to slight cracking,
dulling and surface oxidation.

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 Evaluation and in process monitoring of
sterilization and disinfection procedures
 (1) Evaluation and monitoring of sterilization
• There are 3 methods of monitoring sterilization.
• These methods/indicators evaluate both the sterilization
conditions and effectiveness.
• Mechanical indicators; includes assessing cycle time,
temperature and pressure by observing the displays on the
sterilizers.
• Chemical indicators; allow detection of equipment mal
functioning and help in identifying procedural errors.
• Biologic indicators; are the most accepted for monitoring the
sterilization process.
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 (2) Testing of Disinfectants
• A disinfectant must be tested to know the required
effective dilution, the time taken to effect disinfection and
to periodically monitor its activity.
• As disinfectants are known to lose their activity on standing
as well as in the presence of organic matter, their activity
must be periodically tested.

• Different methods are: 1) Koch’s method 2). Rideal Walker

Method 3). Chick Martin test 4). Capacity use dilution test
and 5). In-use tests.
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Factors affecting the efficiency of
disinfection and sterilization

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Instrument processing pathway

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 References
• Texbook of microbiology by Prof. CP Baveja.(3rd edition)
• Operative dentistry chp- infection control by Studervant.(4th
edition)
• Essentials of preventive and community dentistry Soben peter
(3rd edition)
• Textbook of clinical periodontology, Newman, Takei, Carranza,
11th edition.
• WHO glossary Article on Sterilization of Suture material by Ingrid
Cox dated 2004 17(50) from Community Eye Health Journal.
• Article on effects of sterilisation on periodontal instruments by
Roger B. Parkes and Robert A. KolstadfAccepted for publication 31
August 1981 Journ Periodon

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• Sterilization and disinfection of dental instruments by ADA
• Disinfection & sterilization of dental instruments TB MED
266, 1995
• CDC, guidelines for disinfection & sterilization in health care
facilities 2008.
• Infection prevention and control, college of respiratory
therapists Ontario, june 2011
• New CDC guidelines for selected infection control
procedures, chris miller.
• CDC guidelines for infection control in dental health care
settings, Dec19, 2003/vol.52.
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Thank you

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