1

A very good morning

2

A comparison of four different methods for sterilizing orthodontic pliers

- George Kyritis, jco, June 2012 volume issue 6

-

3

CONTENTSINTRODUCTIONDEFINITIONSHISTORY DIFFERENT METHODS ORTHODONTIC INSTRUMENTSTHE MAIN ARTICLERESULTSDISCUSSIONSUPPORTING ARTICLESCONCLUSION

4

INTRODUCTION

On a daily basis, the practising dentist and his personal are at risk of being exposed to a wide range of patients with blood borne diseases such as HIV/AIDS, hepatitis B,C and air borne diseases such as tuberculosis.

Because of repeated exposure to micro-organisms in blood and saliva, incidence of certain infectious disease has been significantly higher among dental professionals than observed for general population.

5

INTRODUCTION

Orthodontists do not perform oral surgery, but come in contact with blood and oral fluids of healthy patients or infectious patients when doing the orthodontic treatment.

Of all the Dental health care personal(DHCP), the rate of infection among orthodontists, is very high, second only to oral surgery specialists, as saliva is as infectious as blood.

6

HISTORY

LOUIS PASTEUR (1822-95) was the first scientist to show clearly that bacteria never generate spontaneously and that no growth of any kind occurs in the sterilized media.

Dr. Joseph Lister (1827-1912) Discovered the effectiveness of 'carbolic acid,‘ which was used in controlling typhoid. Using carbolic acid, Lister was able to keep his hospital ward in Glasgow free of infection for nine months.

7

carbolic spray, copper, brass with wood handle

Carbolic acid spray being used at the time of a surgery

8

Despite the fact that the germ theory of disease had been established in 1877, it was not universally accepted until 1882 when Koch presented his masterly paper on ‘The etiology to tuberculosis’ giving details of the isolation of the tubercle bacillus.

9

DEFINITIONS

STERILIZATION

It is defined as the process by which an article, surface, or medium is freed of all microorganisms either in vegetative or spore state. (Panikar)

Denoting the use of physical or chemical agents to eliminate all viable microbes, including all bacteria, viruses and spores. (Jerry R. Mc Ghee)

The process of completely eliminating microbial viability (J.C.O. 1993)

10

DISINFECTION:

Disinfection means the destruction of all pathogenic organisms or organisms capable of giving rise to infection. (Panikar)

ASEPSISThe absence of infection or infectious

materials or agents. (Miller)

11

CATEGORIZATION OF INSTRUMENTS

Critical instrumentsIf an instrument

will be used to penetrate tissue or to touch bone it must be sterilized.

12

Semi-critical instrumentsSemi-critical instruments:

mirror, probe, and tweezers.

If an instrument will touch mucous membranes, but will not be used to penetrate tissue or to touch bone, it should be sterilized if at all possible or,. If the instrument is susceptible to heat damage, it should be subjected to high-level disinfection.

13

Non-critical instruments

These are defined as equipment and surfaces which contact only intact skin, such as mixing slabs and spatulas. Work surfaces are decontaminated by using intermediate-level disinfection

14

DIFFERENT METHODS OF STERILIZATION

Dry heat sterilizationFlamingHot air ovenGlass bead sterilizerAutoclavingEthylene oxide sterilizationChemical immersion/cold sterilizationAlcoholLaser

15

IN THE PRESENT ARTICLE

The author has basically tired to compare four different methods of sterilizing the orthodontic pliers and their efficiency.

Wrapped cassettes in M11 ultraclaveV- shaped pouches in M11 ultraclaveWrapped cassettes in statim 5000V shaped pouches in statim 5000

STATI STATIUM M 5000

M 11 ULTRACLAVE

16

Following the CDC guidelines

1.After cleaning , instruments should be bagged in a pouch of appropriate size or placed in a cassette that is subsequently wrapped

2. Hinged instruments, including pliers should be processed in open position.

3. A chemical indicator should be placed inside each pack.4. The sterilizer should be loaded as instructed by the

manufacturer and pouches and cassettes should be separated

5. Sufficient drying time is necessary after sterilization, because wet pouches and wrapping are permeable to microorganisms.

17

Materials and methods

18

Successful decontamination involves four steps: Pre- sterilization cleaningPackagingSterilizationAdequate storage

19

50 othodontic pliers were collected and 5 handpieces. -10 weingart pliers - 8 matheiu pliers - 5 ligature cutters - 8 distal end cutters - 4 three prong pliers -5 bird beak pliers pouches for sterilization

-5 tweeds pliers -3 braceket removing pliers -2 posterior band removers -5 handpieces

20

IMS double decker cassettes were chosen for the cassette sterilization cycle because of there ability to hold pliers in open position.

V shaped pouches especially designed for the hinged instruments were used for the pouched instrument cycle.

21

A fully loaded M11 ultraclave sterilizer could accommodate eight cassettes and five pouched handpieces.

A statim sterilizer could hold one cassette and three pouched hand pieces.

22

In the cycles using V-shaped instrument pouches, the M11 Ultraclave sterilizer held a maximum of 42 pouches and the Statim 50 only 16 pouches.

A Class 5 steam sterilization integrator was placed inside each pouch and in the middle of each cassette to verify the sterilization.

23

Both machines were fully automatic sterilizers equipped with microprocessor controls and LCD panels. The sterilization cycle was set at 132 O-135 O C and 5- 6 minute sterilization time.

The test was repeated three times by two different operators and the average time for each step was calculated

24

RESULTS

25

To evaluate the efficiency of each sterilization method, the average total time processing time per instrument was calculated.

26

By measurment the most efficient method was the M11 ultraclave with V pouches.

The least efficient was statim 5000 with cassettes.

These results suggest that smaller sterilizers are less efficient than the large capacity sterilizers when pliers are wrapped and autoclaved in accordance with CDC guidelines.

27

DISCUSSION

28

Advantages……

This study follows the CDC recommendations on wrapping and packing of instruments prior to sterilization.

V shaped pouches specifically designed for hinged instruments wee used for the pouch sterilization cycle.

Integrated Class 5 chemical indicator was used which allowed the dentist and the staff to verify that the instruments were properly sterilized.

29

Shortcomings.. There has been no comparison between dry

heat sterilization. Since these days pliers are manufactured with the medical grade stainless steel with carbide burs. So, corrosion and dulling associated is no longer an issue.

The bagging and wrapping prior to sterilization , can be a challenge for a busy orthodontic office because of large number of pliers used everyday.

30

Shortcomings..

It is important to use a sterilization method that not only ensures patient safety by following CDC guidelines but also allows rapid instrument turnover in the clinic.

The amount of time , material and energy wasted in reprocessing unused instruments was not addressed in this study.

Further investigations are needed to allow better appraisal of all currently available sterilization methods and equipments.

31

Supporting articles

32

Effective disinfection of orthodontic pliers. J Orofac Orthop. 2006 Sep;67(5):316-36.

Wichelhaus A, Bader F, Sander FG, Krieger D Mertens T.

It should be possible to disinfect lipophilic viruses and the usual bacterial infections adequately with all methods, provided that the use of sprays and through disinfection is preceded by cleaning with brush and water, followed by drying. With hydrophilic viruses, however, the spray and trough disinfection methods are limited in their efficacy and cannot be considered adequate.

Exclusively chemical methods are therefore less effective than thermal or physical-chemical methods. The ultrasound bath and thermal disinfection can therefore be recommended for the disinfection of orthodontic pliers.

33

Effect of steam versus dry-heat sterilization on the wear of orthodontic ligature-cutting pliers.

Am J Orthod Dentofacial Orthop. 2002May;121(5):467-71.

There was no significant difference in the mean wear at the tip of the pliers between the 2groups. It appears that there is no need to maintain both sterilization systems, dry heat and steam autoclave, in the orthodontic office. Steam autoclave sterilization can be used with no deleterious effects on the pliers if they are manufactured with stainless steel inserts.

34

Corrosion of orthodontic pliers using different sterilization procedures.

J Orofac Orthop. 2004 Nov;65(6):501-11.

This study showed that heat sterilization leads to less corrosion than cold disinfection. Corroded pliers can be restored to a useable condition by re-polishing, though it is important that the instructions for their care be strictly adhered to.

35

The effect of routine steam autoclaving on orthodontic pliers.

Eur J Orthod. 1993 Aug;15(4):281-90.

It is likely that the most important factor, when setting up this type of sterilizing method for orthodontic instruments, is to establish a careful and meticulous routine for cleaning, lubricating, and steam autoclaving pliers.

36

Glass bead sterilization of orthodontic pliers

J Dent Assoc Thai. 1990 Jul-Aug;40(4):177-84.

The result showed that after the pliers were scrubbed with alcohol and sterilized for 3 minutes with glass bead sterilizer, all vegetative cells and bacterial spores were killed in every test. This study indicated that glass bead sterilizer is capable of sterilizing orthodontic pliers and can be a useful adjunct when rapid chair side sterilization is desired.

Microbiological evaluation of elastomeric chains. Giovana R. Casaccia et al, Angle Orthod,Vol

77,No.5,2007

No evidence of any biological contamination due to their manufacturing processes .During clinical use care should be taken to avoid contamination by pathogenic organisms. Precut lengths of the chains would greatly reduce the risk of any biological contamination.

38

An initial assessment of the effect on orthodontic pliers of various

sterilization/disinfection regimes. No statistical evidence was found of routine

autoclaving causing more damage to pliers than cold disinfection; in fact, the data suggested the contrary. Chrome plated pliers appeared more resistant to damage and maintained their appearance better than stainless steel pliers.

39

CONCLUSION

40

The packaging and sterilization methods described in this study comply with all CDC recommendations pertaining to the need to sterilize hinged instruments in open position.

For both sterilizers V- shaped sterilization pouches allowed more pliers than popular cassette system.

41

The study also indicates that sterilizers with smaller chambers are less efficient than large capacity sterilizers in processing wrapped orthodontic instruments.

Because of the heightened public awareness of the dangers of cross- contamination and the increased media attention paid to the rise of new infectious agents and the treatment-resistant organisms, orthodontists should expect CDC guidelines to become mandatory. As they already have in California and part of Europe.

42

As the age old saying goes “prevention is better than cure” but precaution is best and must.

so we as orthodontist hold a great responsibility towards the society to not only eradicate diseases but also prevent their spread by following simple sterilization protocols.

It might be a little time consuming but then we all know that a “health is wealth” and

that a “healthy mind stays in an healthy body”

43

ReferencesText book of microbiology -R.Ananthnarayan & C.K.J.PanikerGlass bead sterilization of orthodontic bands

AJODO; Sept 1986 -Gerald.E.Smith

An initial assessment of the effect on orthodontic pliers of various sterilization/disinfection regimes.

Microbiological evaluation of elastomeric chains. Giovana R. Casaccia et al, Angle Orthod,Vol 77,No.5,2007

44

Effect of steam versus dry-heat sterilization on the wear of orthodontic ligature-cutting pliers.

Am J Orthod Dentofacial Orthop. 2002May;121(5):467-71.

Microbiological evaluation of elastomeric chains.Giovana R. Casaccia et al, Angle Orthod,Vol 77,No.5,2007

45

Thank you

- Sneh Kalgotra1st year PG.