Principles and Techniques of Instrument Processing and Sterilization

Learning Objectives Lesson 21.1: CDC Guidelines 1. Pronounce, define, and spell the key terms. 2. Discuss the classification of patient care items, including the following: List the seven steps involved in processing dental instruments. Describe the Centers for Disease Control and Prevention (CDC) guidelines for sterilization and disinfection of patient care items. Describe the classification of instruments used to determine the type of processing. 3. Discuss how a dental assistant can be exposed to microorganisms through dental instruments or other patient care items and which CDC guidelines are in place to limit that exposure. 4. Describe the ideal instrument processing area. Copyright 2018, Elsevier Inc. All Rights Reserved. 2

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 Copyright 2018, Elsevier Inc. All Rights Reserved. 3

Classification of Patient Care Items These categories help determine which sterilization methods best ensure the safety of dental care workers and patients Categories are based on the risk of infection associated with their intended use Classifications are used to determine the minimal type of posttreatment processing Copyright 2018, Elsevier Inc. All Rights Reserved. 5

Classification of Instruments Critical instruments Items used to penetrate soft tissue or bone Greatest risk of transmitting infection and must be sterilized by heat Semicritical instruments Touch mucous membranes or nonintact skin Lower transmission risk Sterilized by heat or receive minimum high-level disinfection if not heat tolerant Copyright 2018, Elsevier Inc. All Rights Reserved. 6

Classification of Instruments (Cont.) Noncritical instruments Contact only intact skin Low risk of infection transmission Cleaned and processed with EPA-registered intermediate- or low-level disinfectant Copyright 2018, Elsevier Inc. All Rights Reserved. 7

Personal Protective Equipment You must always use personal protective equipment (PPE) when processing instruments This includes utility gloves, mask, eyewear, and protective clothing Copyright 2018, Elsevier Inc. All Rights Reserved. 9

Transporting and Processing Contaminated Patient Care Items The dental assistant may be exposed to microorganisms through contact with contaminated instruments or other patient care items Exposure can occur through percutaneous injury (e.g., needle sticks, cuts) or contact with the mucous membranes of the eyes, nose, or mouth Copyright 2018, Elsevier Inc. All Rights Reserved. 10

Instrument-Processing Area Should be centrally located in the office to allow easy access from all patient care areas Dedicated only to instrument processing Physically separated from operatories and laboratory Not be part of a common walkway Copyright 2018, Elsevier Inc. All Rights Reserved. 11

Instrument-Processing Area (Cont.) Needs good air circulation Large enough to accommodate all equipment and supplies The area should not have a door or windows that open to the outside because dust may enter the area Multiple outlets and proper lighting, water, and an air line and a vacuum line for flushing high-speed handpieces Copyright 2018, Elsevier Inc. All Rights Reserved. 12

Instrument-Processing Area (Cont.) A deep sink should have hands-free control for instrument rinsing and (if space permits) a foot-operated or other hands-free trash receptacle The flooring should be an uncarpeted, seamless, hard surface The size, shape, and accessories of the instrument-processing area vary among dental offices Copyright 2018, Elsevier Inc. All Rights Reserved. 13

Workflow Pattern Regardless of the size or shape of the instrument-processing area, four basic areas govern the pattern of workflow Processing of instruments should proceed in a single loop, from dirty to clean to sterile to storage, without ever doubling back If the instrument-processing area is small, you can use signs that read: Contaminated items only Precleaning area Cleaned items only Sterile items only Copyright 2018, Elsevier Inc. All Rights Reserved. 15

Contaminated Area All soiled instruments are brought into the contaminated area, the initial receiving area, where they are held for processing Any disposable items that have not already been discarded in the treatment room are removed from the instrument tray and disposed of as contaminated waste Thorough cleaning should be done before all disinfection and sterilization processes Removal of all debris and organic materials (e.g., blood and saliva) The contaminated area contains clean protective eyewear and utility gloves, counter space, a sink, a waste disposal container, holding solution, an ultrasonic cleaner, an eyewash station, and supplies for wrapping of instruments before sterilization Copyright 2018, Elsevier Inc. All Rights Reserved. 17

Preparation and Packaging Area In this area, cleaned instruments and other dental supplies should be inspected, assembled into sets or trays, and wrapped or placed in packages for sterilization The preparation and packaging area should consist of counter space and storage space for sterilized instruments, fresh disposable supplies, and prepared trays or instrument cassettes Clean instruments are not sterile and could harbor pathogens Instruments must be packaged and sterilized before they are used on a patient Copyright 2018, Elsevier Inc. All Rights Reserved. 19

Learning Objectives Lesson 21.2: Precleaning and Packaging Instruments 5. Discuss precleaning and packaging of instruments, including the following: Explain the purpose of a holding solution. Describe the safety precautions that are necessary when one is operating an ultrasonic cleaner. Describe the precautions that are necessary when one is packaging materials for sterilization. Describe the CDC guidelines for preparing and packaging instruments for sterilization. Describe the CDC guidelines for sterilization of unwrapped instruments. Copyright 2018, Elsevier Inc. All Rights Reserved. 21

Precleaning and Packaging Instruments Instruments may be precleaned in one of three ways: Hand scrubbing Ultrasonic cleaning Instrument-washing machine Copyright 2018, Elsevier Inc. All Rights Reserved. 22

Holding Solution If instruments cannot be cleaned immediately after a procedure, they should be placed in a holding solution to prevent the drying of blood and debris on the instruments The holding solution may be any noncorrosive liquid A commercial enzymatic solution that partially dissolves organic debris may be used Dishwasher detergent also makes a good holding solution because it is low-cost, low-foaming, and readily available It is neither cost-effective nor desirable to use a disinfectant alone as a holding solution Copyright 2018, Elsevier Inc. All Rights Reserved. 23

Holding Solution (Cont.) The container must have a lid and must be labeled with: A biohazard label (because of the contaminated instruments) A chemical label (because of the cleaner/detergent) The holding solution should be changed at least twice daily, and even more frequently if it becomes clouded Remember, a holding solution is necessary only when contaminated instruments cannot be processed immediately Copyright 2018, Elsevier Inc. All Rights Reserved. 24

Hand Scrubbing Hand scrubbing is the least desirable method of cleaning instruments because it requires direct hand contact with the contaminated instrument Copyright 2018, Elsevier Inc. All Rights Reserved. 26

Hand Scrubbing Precautions Wear goggle-type eyewear and puncture-resistant gloves, as well as your protective clothing Clean only one or two instruments at a time Use only a long-handled brush, preferably one with a hand guard or wide surface Keep items above the waterline; fully immersing them in a basin of soapy water interferes with one s ability to see the sharp ends Allow instruments to air-dry or carefully pat them with thick toweling Never rub or roll instruments while they are in a towel because of the risk of accidental injury Copyright 2018, Elsevier Inc. All Rights Reserved. 27

Ultrasonic Cleaning Used to loosen and remove debris from instruments Also reduces the risk of cuts and punctures to the hands during the cleaning process Puncture-resistant utility gloves, a mask, protective eyewear, and a protective gown should always be worn when the ultrasonic cleaner is being used Keep a set of tongs near the ultrasonic unit; these can be used to remove instruments after the cleaning cycle has been completed Copyright 2018, Elsevier Inc. All Rights Reserved. 28

Ultrasonic Cleaner (Cont.) Works by producing sound waves beyond the range of human hearing Sound waves, which can travel through metal and glass containers, cause cavitation (formation of bubbles in liquid) Bubbles burst by implosion Instruments should be processed in the ultrasonic cleaner until they are visibly clean Time varies from 5 to 15 minutes, depending on amount and type of material on the instruments and the efficiency of the ultrasonic unit Copyright 2018, Elsevier Inc. All Rights Reserved. 31

Ultrasonic Cleaning Solutions Only use ultrasonic solutions that are specially formulated for use in the ultrasonic cleaner Some ultrasonic cleaning products have enzyme activity Other ultrasonic cleaning products have antimicrobial activity, which reduces the buildup of microbes in the solutions with repeated use Antimicrobial activity does not disinfect the instruments; it merely prevents the microorganisms from multiplying Copyright 2018, Elsevier Inc. All Rights Reserved. 32

Commercial Cleaners Ultrasonic cleaning solutions come in a variety of sizes and types: Packets (1 oz) Tablets Concentrate solutions Ready-mixed gallon containers Courtesy Certol, Commerce City, CO. 2017 Crosstex International, Inc. Copyright 2018, Elsevier Inc. All Rights Reserved. 33

More About Ultrasonic Cleaning Solutions Do not use other chemicals such as plain disinfectants in the ultrasonic cleaner Some disinfectants can fix the blood and debris on the instruments, making subsequent cleaning more difficult Specific ultrasonic solutions are available for the removal of difficult materials such as cement, tartar, stains, plaster, and alginate Refer to the instructions of the ultrasonic unit s manufacturer regarding the specific solution to be used The ultrasonic cleaning unit should be labeled with both a chemical label and a biohazard label because it contains a chemical and contaminated instruments Copyright 2018, Elsevier Inc. All Rights Reserved. 34

Care of the Ultrasonic Cleaner The ultrasonic cleaning solution is highly contaminated and must be discarded at least once a day or sooner if it becomes visibly cloudy When the solution is being changed, the inside of the pan and lid should be rinsed with water, disinfected, rinsed again, and dried All PPE should be worn while solutions are being changed in the ultrasonic cleaner Copyright 2018, Elsevier Inc. All Rights Reserved. 36

Testing the Ultrasonic Cleaner If you notice that the instruments are not being cleaned completely with processing in the ultrasonic cleaner, the unit may not be functioning properly To determine whether the ultrasonic cleaner is working properly, hold a 5 5-inch sheet of lightweight aluminum foil vertically (like a curtain) half-submerged in fresh, unused solution Run the unit for 20 seconds, then hold foil up to the light Surfaces that were submerged should be evenly marked with a tiny pebbling effect over the entire surface An area without pebbling of more than ½ inch indicates a problem with the unit, and it needs to be serviced by the manufacturer Copyright 2018, Elsevier Inc. All Rights Reserved. 37

Automated Washers/Disinfectors Look and work similar to a household dishwasher Must be approved by the U.S. Food and Drug Administration Use a combination of very hot recirculating water and detergents to remove organic material After washing, the instruments are automatically dried These units are classified as thermal disinfectors because they have a disinfecting cycle that subjects the instruments to a level of heat that kills most vegetative microorganisms Instruments processed in an automatic washer/disinfector must be wrapped and sterilized before use on a patient Copyright 2018, Elsevier Inc. All Rights Reserved. 38

Drying, Lubrication, and Corrosion Control Instruments and burs made of carbon steel will rust during steam sterilization Rust inhibitors such as sodium nitrate and commercial products can be used to help reduce rust and corrosion An alternative to a rust inhibitor is to dry the instrument thoroughly with the use of dry heat or unsaturated chemical vapor sterilization (discussed later), which does not cause rusting Copyright 2018, Elsevier Inc. All Rights Reserved. 39

Packaging Instruments Before sterilization, the instruments should be wrapped or packaged to protect them from becoming contaminated after sterilization When instruments are sterilized without being packaged, they are exposed to the environment as soon as the sterilizer door is opened They can be contaminated by aerosols in the air, dust, improper handling, or contact with nonsterile surfaces Additional advantage to packaging instruments is they can be grouped into special setups, such as crown/bridge, amalgam, prophylactic, or composite Copyright 2018, Elsevier Inc. All Rights Reserved. 40

Packaging Materials Sterilization packaging materials and cassettes are medical devices and therefore must be FDA-approved It is of critical importance to use only products and materials that are labeled as sterilization packaging Never substitute products such as plastic wraps, paper, or zipper-lock freezer bags that are not registered for this purpose Specific types of packaging material are available for each method of sterilization Copyright 2018, Elsevier Inc. All Rights Reserved. 41

Sterilization of Unwrapped Instruments An unwrapped cycle (sometimes called flash sterilization) is a method for sterilizing unwrapped patient care items for immediate use The time for unwrapped sterilization cycles depends on the type of sterilizer and the type of item (i.e., porous or nonporous) to be sterilized Unwrapped sterilization should be used only under certain conditions Copyright 2018, Elsevier Inc. All Rights Reserved. 44

Learning Objectives Lesson 21.3: Methods of Sterilization and Monitoring Sterilization 6. Discuss methods of sterilization, including the following: Describe the three most common methods of heat sterilization and the advantages and disadvantages of each. Explain the primary disadvantage of flash sterilization. Explain the limitations of liquid chemical sterilants. Explain how sterilization failures can occur. Copyright 2018, Elsevier Inc. All Rights Reserved. 45

Learning Objectives Lesson 21.3: Methods of Sterilization and Monitoring Sterilization (Cont.) 7. Discuss sterilization monitoring, including the following: Describe the three forms of sterilization monitoring. Explain the differences between process indicators and process integrators. Describe when and how biologic monitoring is done. 8. Describe the steps involved in cleaning and sterilizing the high-speed dental handpiece. Copyright 2018, Elsevier Inc. All Rights Reserved. 46

Methods of Sterilization Sterilization destroys all microbial forms, including bacterial spores Sterile is an absolute term; there is no partially sterile or almost sterile All reusable items (critical and semicritical instruments) that come into contact with the patient s blood, saliva, or mucous membranes must be heat sterilized The three most common forms of heat sterilization in the dental office are: Steam Chemical vapor Dry heat Copyright 2018, Elsevier Inc. All Rights Reserved. 47

Steam Autoclave Sterilization An autoclave is used to sterilize dental instruments and other items by means of steam under pressure Steam sterilization involves heating water to generate steam, producing a moist heat that rapidly kills microorganisms As steam fills the sterilizing chamber, the cooler air is pushed from an escape valve, which then closes and allows the pressure to increase It is actually the heat, not the pressure, that kills the microorganisms Copyright 2018, Elsevier Inc. All Rights Reserved. 48

Steam Autoclave Operation Cycles Dental office steam sterilizers usually operate in four cycles: Heat-up cycle Sterilizing cycle Depressurization cycle Drying cycle Different manufacturers provide different features Some have added a pre-sterilization vacuum cycle to their units to remove any air pockets from the chamber before steam enters the chamber Copyright 2018, Elsevier Inc. All Rights Reserved. 49

Steam Autoclave From Miller CH, Palenik CJ: Infection control and management 014, Mosby, Mosby of hazardous material, ed 6, St Louis, 2018, Elsevier. Copyright 2018, Elsevier Inc. All Rights Reserved. 50

Packaging Instruments for Steam Autoclave Sterilization Packaging material must be porous enough to permit steam to penetrate to the instruments inside The packaging material may be fabric but most often is sealed film or paper pouches, nylon tubing, sterilizing wrap, or paper-wrapped cassettes One disadvantage of steam sterilization is that the moisture may cause corrosion on some highcarbon steel instruments Distilled water should be used in autoclaves instead of tap water, which often contains minerals and impurities Copyright 2018, Elsevier Inc. All Rights Reserved. 51

Flash Sterilization Rapid, or flash, sterilization of dental instruments is accomplished by means of rapid heat transfer, steam, and unsaturated chemical vapor Flash sterilization may be used only on instruments that are placed in the chamber unwrapped Flash sterilization should also be used only for instruments that are to be promptly used on removal from the sterilizer It is always the best policy to use a method of sterilization in which the instruments can be packaged before use and remain packaged until the time of use Copyright 2018, Elsevier Inc. All Rights Reserved. 52

Unsaturated Chemical Vapor Sterilization Chemical vapor sterilization is similar to autoclaving, except that a combination of chemicals (alcohol, formaldehyde, ketone, acetone, and water) is used instead of water to create a vapor for sterilization OSHA requires a Safety Data Sheet, or SDS, on the chemical vapor solution because of the chemicals toxicity Copyright 2018, Elsevier Inc. All Rights Reserved. 53

Advantages of Unsaturated Chemical Vapor Sterilization The major advantage of the chemical vapor sterilizer is that it does not rust, dull, or corrode dry metal instruments The low water content of the vapor prevents destruction of items such as endodontic files, orthodontic pliers, wires, bands, and burs A wide range of items can be sterilized routinely without damage Other advantages include the short cycle time and the availability of a dry instrument after the cycle Copyright 2018, Elsevier Inc. All Rights Reserved. 54

Disadvantages of Chemical Vapor Sterilization The primary disadvantage is that adequate ventilation is essential because residual chemical vapors containing formaldehyde and methyl alcohol may 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 Copyright 2018, Elsevier Inc. All Rights Reserved. 55

Filtration and Monitoring of Chemical Vapors Newer sterilizers 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 Older models can usually be retrofitted Formaldehyde monitoring badges, similar to radiation monitoring devices, are available for employees Copyright 2018, Elsevier Inc. All Rights Reserved. 56

Packaging for Unsaturated Chemical Vapor Sterilization Standard packaging for chemical vapor sterilization includes: Film pouches or paper bags Nylon see-through tubing Sterilization wrap Wrapped cassettes Thick or tightly wrapped items require longer exposure because of the inability of the unsaturated chemical vapors to penetrate as well as saturated chemical vapors do under pressure As with autoclaving, closed containers (e.g., solid-metal trays, capped glass vials) and aluminum foil cannot be used in a chemical vapor sterilizer because they prevent sterilizing agent from reaching instruments inside Copyright 2018, Elsevier Inc. All Rights Reserved. 57

Pressure, Temperature, and Time The three major factors in chemical vapor sterilization are: Pressure, which should measure 20 psi Temperature, which should measure 131º C (270º F) Time, which should measure 20 to 40 minutes Copyright 2018, Elsevier Inc. All Rights Reserved. 58

Dry Heat Sterilization Operates by heating air and transferring that heat from the air to the instruments This form of sterilization requires higher temperatures than does steam or chemical vapor sterilization Dry heat sterilizers operate at approximately 160º C to 190º C (320º F to 375º F), depending on the type of sterilizer The advantage of dry heat is that the instruments will not rust if they are thoroughly dry before being placed in the sterilizer There are two types of dry heat sterilizers: Static air and forced air Copyright 2018, Elsevier Inc. All Rights Reserved. 59

Static Air Sterilizers Similar to an oven Heating coils are on the bottom of the chamber, and the hot air rises inside by way of natural convection Heat is transferred from the static (nonmoving) air to the instruments in 1 to 2 hours Disadvantages include amount of time it takes and errors due to incorrect processing time The wrapping material must be heat resistant Copyright 2018, Elsevier Inc. All Rights Reserved. 60

Forced Air Sterilizers Also called the rapid heat transfer sterilizers Circulate the hot air throughout the chamber at a high velocity This action permits rapid transfer of heat energy from the air to the instruments, reducing the time needed for sterilization Exposure time in a forced air sterilizer, after the sterilizing temperature has been reached, ranges from 6 minutes for unpackaged items to 12 minutes for packaged items Copyright 2018, Elsevier Inc. All Rights Reserved. 61

Ethylene Oxide Sterilization The use of ethylene oxide gas is a recognized method of sterilization Carried out at low temperatures, which is an advantage for plastic and rubber items that would melt in heat sterilizers Requires 4 to 12 hours, depending on the sterilizer model, and at least 16 hours of poststerilization aeration is required to remove the gas molecules bound to plastic and rubber surfaces Ineffective on wet items Toxicity is possible if the gas is not handled properly Copyright 2018, Elsevier Inc. All Rights Reserved. 62

Liquid Chemical Sterilants Some types of plastics, such as some rubber dam frames, shade guides, and x-ray film holding devices, are damaged by heat sterilization A liquid sterilant such as 2.0% to 3.4% glutaraldehyde must be used for sterilization of these items Glutaraldehyde requires 10 hours of contact time; anything less than 10 hours is disinfection, not sterilization Be sure you have an MSDS for these products Copyright 2018, Elsevier Inc. All Rights Reserved. 63

Disinfectant/Sterilizer From Bonewit-West K, Hunt SA, Applegate E: Today s medical assistant: clinical & administrative procedures, ed 3, St Louis, 2016, Elsevier. Copyright 2018, Elsevier Inc. All Rights Reserved. 64

Sterilization Failures Sterilization may fail when direct contact for the correct time between the sterilizing agent (chemical or steam) and all surfaces of the items being processed is insufficient Several factors can cause the sterilization process to fail, including improper instrument cleaning or packaging and sterilizer malfunction Copyright 2018, Elsevier Inc. All Rights Reserved. 65

Sterilization Monitoring It is critical that dental instruments be properly sterilized Because microorganisms cannot be seen with the naked eye, the major difficulty in sterilization is determining when an item is sterile Currently, three forms of sterilization monitoring are used: Physical, chemical, and biologic Copyright 2018, Elsevier Inc. All Rights Reserved. 67

Physical Monitoring Involves looking at the gauges and readings on the sterilizer and recording temperatures, pressure, and exposure time Although correct readings do not guarantee sterilization, an incorrect reading is the first signal of a problem Remember that the reading reflects the temperature in the chamber, not inside the pack Copyright 2018, Elsevier Inc. All Rights Reserved. 68

Chemical Monitoring Involves the use of a heat-sensitive chemical that changes color when exposed to certain conditions There are two types of chemical indicators: Process indicators Process integrators Copyright 2018, Elsevier Inc. All Rights Reserved. 69

Process Indicators Process indicators (external) are placed outside the instrument packages before sterilization Examples: Autoclave tape and color-change markings on packages or bags Process indicators simply identify instrument packs that have been exposed to a certain temperature; they do not indicate duration or pressure Process indicators are useful in distinguishing between packages that have been processed and those that have not Copyright 2018, Elsevier Inc. All Rights Reserved. 70

Process Integrators Placed inside instrument packages They respond to a combination of pressure, temperature, and time Process integrators are also known as multiparameter indicators All sterilization factors are integrated Examples: Strips, tabs, or tubes of colored liquid The advantage of placing integrators inside each package is that penetration of the packaging by the sterilizing agent is ensured Copyright 2018, Elsevier Inc. All Rights Reserved. 72

Limitations of Process Integrators Process indicators and integrators provide immediate visual control of sterilizing conditions They do not indicate sterility and are not a replacement for biologic monitoring Copyright 2018, Elsevier Inc. All Rights Reserved. 73

Biologic Monitoring Biologic monitoring (spore testing), is the only way to determine whether sterilization has occurred and all bacteria and endospores have been killed The CDC, American Dental Association, and Office of Safety and Asepsis Procedures Research Foundation recommend at least weekly biologic testing of sterilization equipment Several states also require routine biologic checks at weekly, monthly, or cycle-specific intervals, such as spore testing every 40 hours of use or every 30 days Copyright 2018, Elsevier Inc. All Rights Reserved. 74

Biologic Indicators Also known as spore tests, biologic indicators (BIs) are vials or strips of paper that contain harmless bacterial spores (which are highly resistant to heat) Three BIs are used in testing: Two BIs are placed inside instrument packs, and the sterilizer is operated under normal conditions The third strip is set aside as a control After the load has been sterilized, all BIs are cultured If the spores are killed (a negative culture), the sterilization cycle was successful The culturing of the spore test is usually handled with the use of a mail-in monitoring service Copyright 2018, Elsevier Inc. All Rights Reserved. 75

Handpiece Sterilization High-speed dental handpieces rotate at speeds up to 400,000 revolutions per minute (rpm) Blood, saliva, and tooth fragments, as well as restorative materials, may lodge in the head of the handpiece, where they may be retained and transferred to another patient Dental handpieces must be properly cleaned and heat-sterilized Copyright 2018, Elsevier Inc. All Rights Reserved. 77

Handpiece Flushing Techniques Flushing the handpiece is the best way to remove debris from the head To flush a dental handpiece: Attach a pressurized handpiece cleaner to the intake tube of the handpiece (where the air passes through) Flush the head of the handpiece to remove debris Blow out the handpiece using compressed air to remove debris before sterilization Running coolant water from the dental unit through the handpiece at chairside is insufficient Copyright 2018, Elsevier Inc. All Rights Reserved. 78

Handpiece Sterilizing Techniques Only steam sterilization and chemical vapor sterilizers are recommended because sterilization temperatures should not exceed 275º F (135º C) Handpieces should be packaged in bags, wraps, or packs to protect them from contamination before use Never run a handpiece hot out of the sterilizer, and avoid rapid cool-downs, such as running the handpiece under cold water If handpieces need to be cooled quickly after sterilization, use an air fan to blow roomtemperature air over them Copyright 2018, Elsevier Inc. All Rights Reserved. 79