You don’t have to have 10 years of dental experience to visualize this scene. The assistant brings the client to the treatment room. The client is seated, the dentist enters, and everyone settles in for treatment. The dentist asks for an instrument, the assistant drops it, picks it up, wipes it off on her sleeve and hands it to the dentist. Yuck!! So how important is your job?
Regulatory and Governmental Agencies
Occupational Safety and Health Administration (OSHA) – An agency within the Labor Department. OSHA makes the rules we all follow to keep staff and clients healthy
U.S. Food and Drug Administration (FDA) – Establishes guide lines for x-rays and performance of medical devices
Centers for Disease Control and Prevention (CDC) – Part of U.S. Public Health Services. No regulatory authority over us. Develops evidence bared guidelines for infection control
Microorganisms cause infections in clients/staff 2 ways
Direct contact with infected blood, saliva (eyes, nose, mouth, open sore)
Direct contact with blood/salvia contaminated instruments, surfaces
For a person to be infected, all these conditions must be met
1. The pathogenic organism is strong enough and there are enough of them to cause an infection
2. The organism must be transmitted from the source to the person.
3. The person provides a place for the organisms to multiply
4. The person is not immune.
1. Blood is the most dangerous carrier – even dried blood
2. By 2007, it cost $12.00 in materials to clean a room, sterilize the client’s instruments and replace
We have an organized system of sterilization and instrument circulation. New techniques and technology will consistently change how we do what we do in this section. Be sure to pencil in all changes. Keep these thoughts in mind:
Sterilization is the total destruction of all living micro-organisms.
Disinfection is less effective. It kills viruses and some bacteria.
Therefore, everything that touches the clients should be sterilized if at all possible. There are 3 ways to sterilize instruments.
a. Steam pressure autoclave for 30 mins
b. Cold sterilization for 12 hours.
c. Dry Heat Sterilizes
When instruments are brought back on the trays from the operatories, there are a series of steps required to prepare them for their next use:
( high speeds, slow speeds & surgical handpieces) – require constant maintenance to keep in top condition. Handpieces on the tray should be put in the holding container on the C&S counter. When it is time to clean the handpieces, they should be taken to: _______________. There are different types of handpieces that will be cleaned in a different ways. There are slowspeeds, highspeeds, straight sleeves and latch types.
a. Slowspeed/Lowspeed is a smaller handpiece that you place burs in and help to assist the dentist in removing decay from the tooth. This handpiece operates slowly and only removes the decay area of the tooth without damaging the healthy part of the tooth. Straight sleeves are slowspeeds that are used to adjust dentures and temporary crowns outside of the mouth. The latch type handpieces are used in root canals procedures, for polishing tooth colored fillings and other things. The first step of cleaning the slow speeds is spraying 2 squirts of Midwest handpiece solution in the back end and running it on the cart in the operatories for 20 seconds. After that, 2 drops of Midwest lubricating oil should be added to the bottom of the low speed and run on the cart for 10 seconds. Scrub the head with water on a soft toothbrush to remove debris.
b. A highspeed handpiece is used with a bur on it to cut away the enamel and hard parts of the tooth so that the dentist can see the infected part inside the tooth; this handpiece uses water to cool down the friction heat of the highspeeds. This prevents the high speeds from getting clogged and not being able to release water. Finally, wipe the fiber optic window with an alcohol dampened cotton swab.
The Quatrocare is an automatic handpiece cleaner. It sprays the cleaner through 4 handpieces (high speed, endo heads) at the same time. Remove the bar from the handpiece. Open the unit, connect the handpieces, close the door, and push the start button. Everything is automatic. The cleaning agent is included in the oil lubricant.
After all of the handpieces are cleaned, they need to be sterilized. Handpieces and x-ray Rinn holders and bars are sterilized in the statim. The statim is a steam sterilizer that will sterilize the items in a short amount of time. It does not hold a large amount of instruments. The instruments should go in the statim without a bag on it. However, the instruments can be placed in the bag not sealed and use the unwrapped cycle. Close the statim cassette and push it in. Press unwrapped instruments on the statim panel, followed by the start. Let the cycle dry after it is finished. It may be interrupted at anytime if necessary.
Sharps container (red plastic containers with biohazard label)
1. Replace a container when one is filled with 1 ½ inches from the top.
2. Filled containers go in the regulated biohazard trash.
Hepatitis, AIDS, colds, flu, herpes, mononucleosis, TB, and many other infections are transmitted by blood and saliva. This is how I would like for you to think of infection control.
Contamination → No infection if good procedures
Infection → No disease if properly immunized
Disease → Survive if strong and lucky
It’s easy to see that the place to break the chain is good sterilization procedures.
Operating Instructions for Tuttnauer autoclave provides efficient combination of steam and pressure.
Distilled water – test the water using the tester in drawers by the industrial water distiller. Any reading over 5.0 is bad and you should let your team leader know.
1. Place open bags/unwrapped instruments into cassette – a. Each item separate from all others b. Curved instruments turned down c. Hinged instruments open
2. Check Water Level
3. Push cassette into Statim
4. Display panel will read “select a program”
5. Push button for wrapped instruments
6. Push start
7. Check water-using tester in drawer under distillers. Any reading greater than 5.0 is bad.
8. Once sterilization time is done, there is a 60 minute dry cycle that can be interrupted at any time. Clean – use a scotch bright pad to clean bottom half of cassette to remove dirt build-up.
1. When the bag monitor or the chemical test strip inside the bag doesn’t change color (indicating correct temperature not achieved), re-sterilize the instruments.
2. Don’t use this autoclave until it is safely/correctly sterilizing
3. Place spore test (if previous one failed) or, if package indicator failed, repack the instruments and re-sterilize.
a. Make sure all gauges, dials etc. read properly – 1. Autoclave packed too full? 2. 20 minute cycle time at proper temperature/pressure (15-30psi) plus 5-10 minutes to reach proper pressure. 3. Was sterile water used?
b. If second run is ok, you can use the autoclave, if not let your team leader know.
Indiana University followed up the autoclave failures they received. 25% were caused by a malfunction of the autoclave. 75% were caused by operator mistakes! For example:
a. Autoclave not ran long enough
b. Non autoclave type bags used that steam couldn’t penetrate
c. Autoclave overloaded or improperly located
d. Oversize bags used
e. Instruments packed in too tight in the bag
f. Packages not placed on their sides with space between them
g. Closed metal containers won’t allow steam to penetrate
h. Not cleaning items thoroughly before sterilizing
i. Inadequate temperate, pressure, check rubber gasket seal
j. Problem with equipment
k. Instruments not cleaned properly
l. Cycle interrupted. If this happens, repeat a complete cycle.
m First use of the day. Check instructions – may need to run empty to warm unit up, then use the rest of the day.
Never run more than 5-6 bags per tray at a time. Always use the autoclave for:
a. Everything used for clients on their trays – no plastic or rubber on bottom tray (it may melt)
b. Impression trays (bagged)
c. Syringes and amalgam wells (not bagged)
d. Ultrasonic scaler tips (bagged)
e. Anything you think needs autoclaved
f. Jet Dry Surface at inside of Statim (also Rubber) daily.
Autoclave Strip Failures
If the autoclave test strip fails at the spore test company, they usually can tell within the first 24 hours. They will CALL immediately with that result. The Dental Board still allows us to use the autoclave after one failure reading. If there are two consecutive failures, they require the autoclave not be used and be serviced.
The testing center says “no news, is good news” from them. So if we haven’t heard from them within 2 or 3 days after the test strip has been sent, we are ok.
If questions, please call them at _______________- with our number ______.
Autoclaving is the quickest, safest method of sterilization. Some instruments can’t be autoclaved such as: x-ray film holders, plastic instruments, dappen dishes, or they rust and dull instruments. These instruments are cold sterilized. These sterilizers are located on the counters near the autoclave.
The active ingredient in cold sterilizers is Glutaraldehyde and should be changed weekly (or sooner if daily test strip indicates a weakened solution). The Test Strip is dipped in the solution every day till it turns red (about 3 seconds), set it on a paper towel and wait 15 seconds, if the test strip is still red, then the solution is good, if yellow blotches appear, change the solution. Throw the strip away, and use a new one each day. Do not read the strip after 30 seconds; it can give a false reading.
1. dump old solution down the drain
2. rinse container with water, dry, refill with fresh solution.
Empty items in the cold sterile first thing every morning. Rinse off with hot water, air dry, and blot with towels before putting items away.
This solution has several disadvantages:
1. You can’t tell if you’ve killed everything
2. It takes much longer
3. The solution may not touch all surfaces (where the instruments touch each other) and therefore may not kill all microorganisms.
4. Gluturaldehyde give off fumes above 68ºF, so container must be covered.
No instruments or disposables should be left out, Store in drawers. Always wear heavy-duty gloves, mask, and eye protection when cleaning instruments. Avoid splashes, place instruments in solutions, do not drop them. Cover the container.
1. wear nitrile gloves, mask, and safety glasses.
2. Clean the instruments in the autoclave
3. Only hand scrub for removal of resistant material
4. Allow to dry.
1. Occasionally instruments can’t be cleaned at the end of an appointment. If the instruments are left out, the blood and debris will dry/harden on the instruments. The holding solution keeps them wet until you are ready to clean them.
2. Holding solution is usually the ultrasonic cleaning solution (contains detergents, anti-rust agents, and a neutral pH that won’t harm instruments. Never use gluturaldehyde.
3. Don’t hold for more than 3 hours (increase chance of rusting)
1. Use for burs
2. Failures: a. Operator errors include: i. Overloading and/or ii. Inadequate time, temperature b. Failed equipment c. Time – will take 1-2 hours
How do I know which sterilization method to use?
Instruments are broken down into 3 categories:
A. Critical touch bone or penetrate tissue (scalers, scalpels, etc.)
B. Semi-critical touch saliva (mirrors, amalgam condensers, etc.)
C. Non-critical touch exterior skin (chair, counters, etc.)
Recommendations for Autoclave Maintenance
1. Check cycle time, temperature and pressure gauges daily. Reread the operations manual.
2. Use distilled or deionized water only! No tap water!
3. Check ALL fittings and seals regularly, especially the door gasket; consult the operations manual.
4. Wash all internal surfaces weekly with autoclave cleaner, rinse well.
5. Once a week, place an indicator test paper. When done send to the testing company. These strips show us
a. Correct heat (274 degrees)
b. Correct time (30 minutes)
c. Correct penetration (since it’s in the bag)
1. Place a biologic indicator in an early day bag and mark the bag.
2. Place this bag in the center of the packs being sterilized and sterilize.
3. Record – type of sterilizer, cycle temperature, time, your initials
4. Mail the processed spore test and the control to our monitoring service.
5. Keep a running result of the test results – 1 log book for each sterilizer.
Record the results in your sterilization log.
6. Once every Monday:
a. Place spore indicator strip, out of left side of envelope, in autoclave ,in a pouch between packages, and run normal cycle. Take strip out at end of cycle, put back in white spore check system envelope, seal, stamp and mail. Test must be ran and mailed on the save day. Our mail runs at about 10a.m. These tests are kept in cabinet above autoclave.
b. Every Wednesday, clean inside of chamber and trays with autoclave cleaner (See instructions on bottle) and paper towels. Rinse, drain, and refill after cleaning. Wipe trays and inside of autoclave with Jet Dri.
c. Put 2 drops of oil on each hinge and door-tightening bolt.
Advantages of Steam Sterilizer
1. Quick and easy
2. Very reliable
Disadvantages of steam
1. If instruments left wet, will rust
2. Must package instruments
3. Can dull sharp instruments
Monitoring our sterilizers
Check steps when autoclave sterilizer fails.
1. Was the biological indicator expiration date ok?
2. Was the incubator working properly?
3. Run a second test to confirm results.
Specific Cleaning/Sterilization Procedures
Some things in the office need special cleaning procedures:
Impression trays can be metal or plastic. They are used to place alginate on & to take impressions of people’s teeth.
1. After the metal trays are done being used, the bulk alginate needs to be removed.
2. The trays should be placed in a bucket under the sink in the cleaning & sterilization area.
3. The following day, all of the excess alginate should be removed. A toothbrush & some running water usually do the trick.
4. Ultrasonic the impression trays and then place in the a sterilization bag – size tab showing.
5. Sterilize in autoclave.
6. After the trays are sterilized, they can be kept in separate baskets for upper & lower trays.
(look like little drill bits used to clean the infection out of a tooth during a root canal)
Endo files are used in the root canal procedure to help measure and clean out canals. GT and profiles are also used in the root canal procedure. These are used in to clean out the canals where the nerve and blood vessels were.
1. Used files are kept rubber banded in the contaminated area on the shelf above the C & S area.
2. Gauze moistened with orange solvent will clean files ( use Nitrile gloves)
3. Check files under microscope:
a) All debris off
b) No spirals have “stretched out” or deformed –
This is a weak area that could lead to a breaking of the instrument in a client’s tooth.
4. The endo files get inserted into the gauze in specific numerical order. There are 21mm, 25mm & 30mm files. Place the files in gauze numerically (one of each size) #6,8,10,15 (one pack) 20,25,30,35,40 (one pack)
a) label what files are on front of pack: 21,25,30mm
b) engine (GT files) by length (21,25mm) and taper(2,3,4,6)
c) any extra files-clean and sterilize in separate packs.
5. The endo files should then be placed in a bag & sterilized. Use the coding system:
1st use – red, 2nd – black, 3rd – purple, 4th – pink, gates – use clips
6. The profiles are disposable after used 5 times. The pen slash marks on the tape indicate this.
Root canal file packs are being set up as follows:
In one bag; 21m Gates Glidden – 2,3,4,6 rings in gauze –stoppers, don’t need to record number of times used Handfiles – 6 (pink),8 (gray),10 (purple),15 (white),15 in gauze or 20 through 60 in gauze –stoppers GT or profiles – 2 (red),3 (green),4 (blue),5 (yellow) in gauze –stoppers, 21 or 25mm -profiles can only be used for 7 canals, so be sure to write how many canals you treated on the tape at the top of the profile gauze
In one bag: 25mm Gates Glidden – 2,3,4,6 on gauze – place stoppers Hand files – 6,8,10,15,15, on gauze – place stoppers Profiles – 2,3,4,5 on gauze – place stoppers There are special sized profiles: 30 mm should be bagged in gauze by themselves; there are different sized tapers of the profiles and they should be bagged on gauze by themselves and used only upon request by a doctor.
(also look like little drill bits, used to widen the canal)
They are sterilized like burs, but packed in gauze and bagged. The Gates Glidden are set up in fours II, III, IIII, VI. They can be used as many times as needed. Your dentist will let you know when its time to replace old Gates Glidden.
Gates Glidden are also used in a root canal. They help to open up the canals. The Gates Glidden should be sterilized in the same manner as the endo files. They go into the gauze in a specific order: 2,3,4, They get sterilized in the autoclave.
(profiles are the endo files that go on a handpiece)
All dentists use profiles during endo appointments. Profiles can be used for 7 canals. – place on gauze and put in endo bags – # 2,3,4,5
Burs (these are used for drilling the decay out of teeth) – This only describes cleaning for carbides. We clean diamonds with the “Clean a Diamond” dressing stone
Lab pumice and rag wheels (round, cloth wheel that goes on the lathe used to polish crowns, etc.) Use dilute Clorox 10 to 1 with water (sodium hypochlorite) to wet the pumice. Each evening clean out lathe pan and spray, scrub, spray and let dry with Dentaphene. Remove rag wheel and autoclave. Add new pumice every Tuesday.
(appliance (metal) that you stick into a person’s ears and they bite on a stick – the dentist uses this measurement to determine the upper jaw in relation to their head) Place the “Y” shaped mouthpiece in hot water bath (120 degrees) until soft enough to remove copper wax.
Place in sterilizer bag and run through autoclave. Store in wax drawer.
Oral Surgery Instruments- clean with water and soft cloth.
Completely dry instruments prior to placing in articulator bag. Instruments with joints (scissors, forceps, hemostats) should be placed in the bag in an open position) Seal bag prior to sterilization
High Speed Handpieces (HP)
(1) Remove bur
(2) Wipe HP with alcohol soaked gauze
(3) Place HP on Kavo cleaner
(4) Place HP into autoclave bag
(5) Place in autoclave and run full cycle
(6) Remove and store
If you have specific questions about sterilization techniques and can’t find the answers, call Cottrell Ltd. at 1 800 843 3343.
What causes a positive sporecheck?
1. Sterilizer doesn’t work properly.
2. Packs too full.
3. Too many packs run at one time.
4. Not processed for enough time.
Problem / Cause / Prevention
Spotting / Mineral deposits
1. Check operating instruments and left by slow or operation of autoclave. Improper drying
2. Use chloride free solutions for sterilizing, disinfecting, rinsing, and cleaning. Distilled or mineral free water preferred (approx.7.0)
Rust & Corosion / Film left by steam
1. Check purity of water supply. (Corrosion) steam
2. If water softeners are used, check for composition.
3. Purge steam pipes, especially new installations.
4. Rinse with warm water before autoclaving
Rust / Deposit
1. Do not mix stainless steel with other metals especially where there is evidence of defective plating.
2. Rinse with distilled water (particularly important where tap water may have high metallic content).
3. Remove all debris from lock areas, teeth, etc.
4. Dry all instruments thoroughly. Use full time cycle. This is most important when instruments are wrapped.
5. Thoroughly clean all interior surfaces of sterilizer.
6. Drain water reservoir, refill with ½ pint vinegar and distilled water. Run 3 sterilization cycles. Empty.
Pitting / Chemical and electronic attack of surfaces
1. Rinse instruments thoroughly immediately after use.
2. Avoid long exposure to chlorides and acids.
3. Do not use detergents having high pH levels. (should be neutral pH)
4. Do not mix different metals in ultrasonic cleaners.
Black to purple compounds / Ammonia
1. Avoid exposure to stains ammonia in solutions and cleaning .
2. Rinse instruments thoroughly (distilled water preferred).
Brown stains / Dried blood
1. Check water supply in sterilizer.
2. Check cleaning compounds and detergents. Avoid excessive use.
3. Rinse and clean instruments throughly
White Stains / Mineral Deposits
1. Use proper drying cycle
2. Use distilled water
1. Clean up operatory, carry disposables, instruments, handpieces to sterilization area
2. Sort out non-disposables, dispose of all else
3. Handpieces – remove bur, wipe external surface
4. Handpieces – follow maintenance instructions
5.Instruments – place in ultrasonic
6. Instruments –dry remove any blood and debris with running water, brush if necessary
7. Rinse with clean water
8. Place in pouch
9. Sterilize, dry
Draw pictures of sterilization areas and label what goes where for each step.
Dirty trays placed here
Chemical / biologic indicators
Cleaning of instruments
Tray make up area
Chairside assistant has read and routinely applies information in this section.
Watch “If Saliva Were Red”
_____________________________ ___________________ Trainer Date