Infection Control of Armamentarium

Infection control of an orthodontist armamentarium ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) Review Article

Infection control of an orthodontist armamentarium: A clinically oriented review

Ambesh Kumar Rai 1* , Bipin Kumar Yadav 2

1Senior Resident-Orthodontist, Department of Dentistry, UP Rural Institute of Medical Sciences (UPRIMS), Saifai, Etawah, Uttar Pradesh, India 2Assis tant professor in Periodontics, UPRIMS, Saifai, Etawah, Uttar Pradesh, India *Corresponding author email: [email protected] How to cite this article: Ambesh Kumar Rai, Bipin Kumar Yadav. Infection control of an orthodontist armamentarium: A clinically oriented review . IAIM, 2015; 2(5): 218-224. Available online at www.iaimjournal.com Received on: 10-04-2015 Accepted on: 04-05-2015

Abstract The implementation and execution of effective infection control protocols among all health care communities cannot be overstressed. Infection control becomes even more significant in dentistry as more microorganisms are found in the oral cavity than in any other part of the body. Saliva is about half as infectious as blood, and the most likely modes of transmission in dental offices are through puncture wounds, skin abrasions, or lesions. Dental aerosols, splattering, and instrument contamination can also t ransmit virus, which can survive for several weeks at room temperature. With Orthodontists showing the second highest incidence of hepatitis B among dental professionals, the need of stringent infection control protocol in an orthodontic office becomes man datory. This article discusses various sterilization protocols with their relevant scientific data keeping the instruments longevity in mind to facilitate the discerning orthodontist in make an informed decision towards their implementation.

Key words Infection control, Orthodontic instruments, Sterilization.

Introduction Sterilization refers to any process that Orthodontic offices is often stated to fall short in effectively kills or eliminates transmissible following infection control protocols despite the agents from a surface, equipment, article of fact that orthodontist’s are se cond only to oral food or medi cation, or biological culture surgeons in contracting infections like hepatitis medium. Sterilization can be achieved through which are occupationally related [1, 2, 3]. the application of heat, chemicals, irradiation, high pressure or filtration.

Infection control of an orthodontist armamentarium ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) Disinfection may be defined as cleaning an Infection control in orthodontic office article of some or all of the pathogenic Basic requirements organisms which may cause infection. The following equipments are deemed as Disinfectants are antimicrobial agents that are essential requirements for implementing and applied to the nonliving objects to destroy maintaining effective infection control standards microorganisms. in your orthodontic office • Ultrasonic cleaning Unit (for Payne has explained the three possible debridement and pre -cleaning pathways of cross-contaminat ion and its protocols). handling methods as • Desktop Autoclave St erilizer. • Critical: Instruments th at penetrate the • Dry-Heat Sterilizer. mucosa must be sterilized. • Ultraviolet cabinet. • Semicritical: Instruments that touch the • Chemical immersion or cold sterilization. mucosa should be sterilized. • Glass Bead sterilization. • Least critical: Surfaces touched during

treatment should be disinfected. Ultrasonic u nit (for debridement and pre -

cleaning) Using this as a guide, scalers, scalpels, and other Ultrasonic units are the present day protocols tissue-cutting instruments must be sterilized. for the pre-cleaning of hand instruments. They Other hand instruments and pliers should be involve the debridement of instruments under sterilized. Work surfaces, triplex syringe handles, running water by direct pre -cleaning in specially operating light handles, and other designed containers and cassettes [6]. Solutions environmental surfaces should be disinfected with anti-rust compositions and enzyme - based [4]. solutions designed for breakdown of

contaminants and particles are recommended. The advice sheet issued for infection cont rol in Pre-cleaning cycles last for 5 -15 minutes dentistry issued, from the Department of depending upon instrument load. It is crucial Health, United Kingdom enumerates three that any trace of residual moisture is eliminated stages to sterilization or decontamination through appropriate drying measures process being; pre-sterilization cleaning, (compressed air) after the pre -cleaning stage. sterilization and storage [5]. Pre sence of moisture in between the joints and

tips of pliers increases the corrosive tendency in A planned and designated area within the clinic instruments. setting would facilitate a sequenced and scheduled sterilization protocol where pre - Desktop autoclave s terilizer allotted disinfection and storage areas will Autoclaving is regarded as Gold standard for demarcate as well as segregate the effective sterilization. Instruments are subjected contaminated from the sterilized and ready to to steam under press ure (15 psi) at a use instruments. Additionally, water for rinsin g temperature of 121 degree to 134 degree of instruments should be from sources which Centigrade (250 degree 273 degree Fahrenheit) are free of contaminants and of the highest Conventional method involves holding time of filtered quality (Ro Systems). Also, drying 15 minutes for 121 degree Centigrade or rapid protocols involving compressed air must be from cycle involves 134 degree Centigrade for 3 oil-free sources.

Infection control of an orthodontist armamentarium ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) minutes. A cooling down period of 40 minutes to wasted disposal issues of the steri lization 1 hour for rapid and conventional cycles solutions and the corrosion tendency by their respectively is required. Comparative studies on protrac ted exposure. 2% acidic glutara ldehyde various sterilization protocols have reported the and chlorine dioxide are commonly used occurrence of corrosive changes with repeated solutions which have ADA seal of approval. cycles [7]. The presence of steam vapor has been .Sterilization time with 2% acidic glutaraldehyde found to be detrimental for orthodontic pliers. is 10 hours without dil ution and six hours with chlorine dioxide. Comparative studies have Dry-heat sterilizer indicated that cold sterilization predisposes to a It is the best suited means of sterilization for pitting type of corrosion compromising the orthodontic needs due to absence of moisture. integrity of the instrument [13, 14] . It causes oxidative destruction of bacterial protoplasm at a temperature range o f 160 Glass bead sterilization degree Centigrade (320 F) for two hours It is mainly used to steril ize orthodontic bands duration to achieve complete sterilization. Rapid and pliers tips. Small glass beads ranging from dry heat sterilization involves cycles at 1.2 to 1.5 mm in diameter are used as heating temperatures of 190 degree Centigrade (375 F) media with temperature ranging from 217 for 6 to 12 minutes. Instruments must be dry degree Centigrade to 232 degree Centigrade before sterilization, as th e presence of water can (424 degree F to 450 degree F) but not interfere with the sterilization process and exceeding 250 degr ee Centigrade (482 degree F) longevity of orthodontic pliers by dulling their for 3-5 seconds Protocol involving molar band cutting surfaces; thus making it advantageous sterilization reported spore effectiveness at 226 over other sterilization protocols [8-11]. degree Centigrade after 45 seconds for a single band [13]. The size of instrument is directly U. V. cabinet proportional to the heating time requ ired. After sterilization with any above mentioned Although, the possibility of being able to sterilize method instruments must be kept inside an 1-2 Orthodontic pliers within 30 seconds has ultraviolet cabinet so that sterilization of been suggested however, correct positioning instruments is maintained for longer duration U involving the placement of instrument at the V radiation chamber is an enclosed space for the periphery of the glass bead sterilizer is crucial to disinfection of dental instrument and get maximu m effectiveness [14]. These orthodontic pliers with 6 exposures of 5 minutes recommendations however can be deleterious duration according to the manufacturer’s as the instruments are exposed to higher instructions. The optimum wavelength for UV temperature ranges against most manufacturer radiation at peak emission is 260 nm with an warnings of 193 degree Centigrade (380 degree average of 254 nm being adequate for F) thus increasing the risk of altering the steel sterilization [8, 12]. tem per and decreasing the corrosion resistance.

Chemical immersion or cold steril ization Guidelines for sterilization of Cold sterilization is recommended for heat Orthodontists’ paraphernalia sensitive non surgical instruments and alginate Enumerated below are current and rubber based impression materials. recommendations with effectiveness against Protracted exposure time is the chief disadvantage of this method coupled with the

Infection control of an orthodontist armamentarium ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) organisms as well as the longevity of the elimination, recommendations have advocated instrument in mind. autoclave cycles at 121 degree Centigrade for 60 minutes or 134 degree Centigrade for at least 18 Orthodontic pliers minutes or combination cycles involving hot -air • Debridement in ultrasonic cleaner for 5 sterilization followed by autoclaving to improve to 12 minutes (for maximum the margin of the safety. The effects of such effectiveness never overload the unit). extreme prion sterilization protocols on • Rinsing with distilled Water. The orthodontic pliers was evaluated with ligature recommendation of a final rinse with cutters were sterilized through a pro tocol Distilled water following any pre - involving water disinfect ion followed by hot air cleaning protocol is recommended to drying and finally autoclaving at 134 degree of fset the impurities present in tap Centigrade for 20 minutes followed by a cooling water as well as the possibility of ionic period of 1 hour. The study observed that imbalances. surface alterations occurred from the first cycle • Remove excess moisture thorough itself with a blunting of the cutting edges and a drying with compressed oil -free Air. resultant decrease in their cutting efficiency • Lubrication of Plier joints and cutting [15]. edge with silicone based lubricants. Silicone based lubric ating sprays can be Molar bands used for pliers before the dry - heat Molar bands are one of the most overlooked process and after if the instrument is to materials in the orthodontic armamentarium. be stored. Oil-based lubricants are not The sterilization of tried – in pre -formed bands recommended as they tend to clog the has received attention off-lately and numerous pliers. protocols are present in orthodontic literature • Sterilization protocol using a Dry -Heat [16, 17]. Sterilizer at 190 degree Centigr ade (375 degree F) for six to twelve minutes. Sterilization of Pre-formed orthodontic bands Autoclaving is recommended only if a both the in-received state as well as tried -in dry heat sterilizer is not available and ones can be done by the following method . only as a secondary option to dry heat • Ultr asonic cycle for 5 minutes depending sterilization. A shorter cycle at 134 on the capacity of the unit. degree Centigrade for three minutes is • Rinsing with distilled Water. recommended due to the detrimental • Remove excess moisture through drying nature of the process on instruments. with oil-free Compressed Air. Instruments must be wrapped prior to • Sterilization protocol using a Dry -Heat the process after ensuring complete Sterilizer at 190 degree Centigrade for 6 absence of moisture in the instrument. minutes. • Storage in UV chamber to preserve the • Storage. It is recommended that the sterility of the instrument for a longer tried in bands are processed separately duration. in an ultrasonic cleanser or stored separately in containers if they cannot Prions are an extremely stable group of be sterilized immediately. Additionally infectious agents that are resistant to while sterilizing these bands it is conventional sterilization protocols. For Prion important to ensure that th ey are International Archives of Integrated Medicine, Vol. 2, Issue 5, May, 2015. Page 221 Copy right © 2015 , IAIM, All Rights Reserved.

Infection control of an orthodontist armamentarium ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) processed separately from the in - where this is not feasible as in the case of e - received bands. chain spools, it is better to cut a little extra than required and discard the rest. Autoclaving of preformed molars bands can also be carried out as an alternative to dry heat Marking pencils sterilization as the smooth surface of the band Studies have shown that orthodontic marking does not leave any scope for moisture retention; pencils can pick up and transfer bacteria from besides, they can be wrapped and marked if patient to patient during typical orthodontic both in-received and tried-in bands are sterilized procedures from contaminated arch wires. simultaneously. Conventional orthodontic marking pencils Pre-formed bands with welded components (as cannot be autoclaved. Gas steriliza tion is buccal tubes) are not recommended for effective in killing bacteria, but is costly and autoclaving to avoid any weld decay. It is difficult, making it impractical for orthodontic recommended that chemical immersion offices. Soaking or spraying the tips of marking protocols should be limited to bands with pre - pencils with disinfectants could be more weld ed attachments. Longer immersion effective than wiping, but this method is unlikely duration and the lack of any indicator for its to gain a cceptance from practitioners. The only effectiveness make it a less than an ideal choice sure way to avoid potential cross -contamination for sterilization. is to use the inexpensive disposable markers available from orthodontic supply companies Orthodontic wires [20]. Most commonly used preformed nickel titanium and stainless steel wires are available in non Alginate impression sterile single use packs, which could be Common disinfecting solutions that are used for sterilized. Reuse of wire from one patient to alg inate materials include 1% sodium other, though accepted with reservation, is best hypochlorite, sodium dichloroisocyanurate and discouraged due to ethical reasons. Currently 2 % glutaraldehyde. Present recommendations heat sterilization is the most reliable method involve the immersion of alginate impressions using steam autoclavin g at 1210C, 15 -20psi for for not more than 10 minutes in disinfecting 20 min. Chemical sterilization using 2% solutions to prevent alteration in the su rface glutaraldehyde is corrosive and can attack characteristics [21]. metals immersed in them. Guidelines for sterilization of alginate Elastomeric ligatures and c hains impressions Elastomerics and elastomeric ligatures are not • Rinse thoroughly under running water suited for chemical disinfection as they a re following removal from the patients’ known to alter the physical characteristics [18, mouth. 19]. Alcohol wipes are not an alternative as they • Immersions of impression in disinfectant are not effective in the presence of tissue for 10 minutes. Spraying aerosols can be proteins seen in blood and saliva. used follo wed by sealing in an airtight pouch, however, are not recommended Single patient packs are the best insurance due to their unevenness and additional against cross-contamination r isks at present and

Infection control of an orthodontist armamentarium ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) hazard of unavoidable inhalation of disinfection procedures. J. Clin. Orthod., aerosol during spraying. 1988; 22: 22-8. • Rinse again under running water. 4. Payne G. Sterilization and disinfection in • Following this the impression can be the orthodontic office: A practical used for model fabrication [22]. approach. Am J. Orthod & Dentofacial Orthop, 1986; 09: 250 -52. Miscellaneous items 5. Adivce Shee t, infection Control in Cheek retractors can be immersed in procide Dentistry, Department of Health, United overnight because they turn milky after Kingdom, 2005. autoclaving. 6. Hohlt W, Miller C, Need J, Sheidrake M. Bracket positioning Gauges , Hand pieces and Sterilization of orthodontic instruments Photographic mirrors can be sterilized in a kavo - and bands in cassettes. Am J Orthod & klave [23]. Dentofacial Orthop, 1990; 98(5): 411 - Burs can be ste rilized by autoclaving or ethylene 416. oxide exposure for 4-12 hours. 7. Malcolm Jones , Kevin Pizarro, Romola Blunden. The effect of routine steam Conclusion autoclaving on orthodontic pliers. Eur J Orthod, 1993; 15(4): 281 -290. Prevention is the best method of cure. With 8. Mazzsocchi AR, Paganelli C, Morandini rising medico legal concern and increase in C. Effects of 3 types of sterilization on awareness of the masses toward infection orthodontic pliers. J. Clin. Orthod , 1994; control protocols and procedure it is extremely 28: 644-647. important for a practicing dentist in general and 9. Johnston M, Moore W, Rodu B. orthodontist in particular to ensure patient Comparison of convection heat safety by being aware and following strict sterilization units for the orthodontic infection control protocols. This not only will office. Am J Orthod & Dentofacial minimize the hassles of any litigation, thus Orthop, 1991; 99(1 ):57 -63. causing a bad name in an e xtremely competitive 10. Carcao G. Comparison of 3 dry heat market, but also will promote good will with convection sterilizers. J.Clin. Ortho d., patients, thus boosting the practice so that the 1993; 27: 259-263. extra amount spend on sterilization procedures 11. Alberto Mazzocchi. Orthodontic pliers is reimbursed as an increase patient inflow. and Sterilization Procedures, Questions

and Answeers. Virtual Journal of References Orthodontics. 03/09/1996. 1. Matlack RE. Instrument sterilization in 12. Wichelhaus A, Brauchle G, Mertmann M, orthodontic offices. Angle Orthod, Sander FG. Corrosio of orthodontic 1979; 49: 205- 211. pliers using differen t sterilization 2. Robert G Cash. Trends in sterilization procedures. J Orofac Orthop., 2004; and disinfection procedures in 65(6): 501-11. orthodontic offices. Dentofacial 13. Gerald E. Smith. Glass bead sterilization orthopedics, 1990; 98(4): 292-9. of orthodontic bands. J Orthod & 3. Buckthal JE, Mayhew Mj, Kusy R P, Dentofacial Orthop., 1986; 90(3): 243 - Crawford JJ. Survey of sterilization and 249.

Infection control of an orthodontist armamentarium ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) 14. J A Miller, K.M. Harrower, M J Costello. solution on the e lastic properties of Novel method of sterilizing o rthodontic elsastomeric chain. Angle Orthod, 1991; instruments Aust. Orthod J., 1992; 12(3): 61: 25-30. 151-2. 20. Fernando Asce ncio F, Langkamp H, 15. George OF, Benoit C., Rapin L., Aranda Agarwal S, Petrone JA, Piesco NP. P., Berthod P., et al. Effect of Surgical Orthodontic Marking Pencils: A Potential Sterilization Procedures on Orthodontic Source of Cross-Contamination. J Clin Pliers: A Preliminary report. European Orthod., 1998; 35: 307 -10. Cells and Material, 2005; 10(4): 13 . 21. Blair FM, Wassell RW. A Survey of the 16. Dowsing PE, Benson PE. Molar Band Re - methods of disinfection of dental use and Decontamination: A survey of impressions used in dental hospitals in Specialists’. Journal of Orthodontics, the United Kingdom. Br Dent J., 1996; 2006; 33(1): 30-37. 180(10): 369-75. 17. Benson PE, Douglas CWI. 22. Patel MP, Oxford J, Whiley R. Decontamination of orthodontic bands Development of a self -disinfecting following size determination and alg inate impression materia l. cleaning. Journal of Ortho dontics, 2007; Biological and Medicinal Research, 34(1): 18-24. University of London, 2009. 18. Mayberry DR, Allen J, Close Kinney DA. 23. Drake D. Optimizing Orthodontic Effects of disinfection procedures on Sterilization Techniques. J Clin Orthod., elastomeric ligatures. J.Clin. Orthod., 1997; 31(8): 491-8. 1996; 3: 49-51. 19. Jeffries CL, Von Fraunhofer JA. The effects of 2 % alkaline glutaraldehyde

Source of support: Nil Conflict of interest: None declared.