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Cleaning, Maintenance and Sterilization:

B.01 | How should I clean my instruments?
This depends on how sterile your protocol requires them to be. First rinse in pH neutral distilled water and remove blood and debris. Use a fresh neutral pH solvent and then a soft brush for the tough cleaning. If you steam autoclave, make sure that you use manufacturers instructions for your autoclave (clean neutral pH distilled water), and that your high quality instruments are not mixed with instruments of inferior quality. Impurities from the lower quality instrument can start a corrosive action on your good ones. Be sure that the full drying cycle is used. Overlapping joints may have dampness within the joint, increasing the chance of corrosion. This can be prevented in three ways: 1. assure the full drying cycle is complete. 2. apply silicone grease inside the joint as a protective layer.  3. by use of an air canister or hair dryer to blow moisture out of overlapping parts. Instruments can also be cleaned ultrasonically but must be immediately rinsed and dried.

B.02 | What is a central instrument processing area?
In dental health care settings, all instrument cleaning, disinfecting, and sterilizing should occur in a designated central processing area in order to more easily control quality and ensure safety. The instrument processing area should be physically divided into sections for:

  • Receiving, cleaning, and decontamination
  • Preparation, maintenance and packaging
  • Sterilization
  • Storage

This division is designed to contain contaminated items in an area designed specifically for cleaning, thus preventing contamination of the clean areas where packaging, sterilization, and storage of sterile items occurs. Re-usable contaminated instruments and devices are received, sorted, and cleaned in the cleaning area. The packaging area is for inspecting, assembling, and packaging clean instruments in preparation for final processing. The sterilization and storage areas contain the sterilizers and related supplies, as well as incubators for analyzing spore tests, and can contain enclosed storage for sterile items and disposable (single-use) items. When it is not possible to have physical separation of these areas, clearly labeling each area (i.g from contaminated to sterile) might be satisfactory if the personnel who process the instruments are trained in work practices to prevent contamination of clean areas.

B.03 | Why must instruments be cleaned before being sterilized?
Cleaning should precede all disinfection and sterilization processes. Cleaning involves the removal of debris (organic or inorganic) from an instrument or device. If visible debris is not removed, it will interfere with microbial inactivation and can compromise the disinfection or sterilization process. 
Remember: sterilization does not clean.

B.04 | Which is the best method for cleaning instruments, manual (brush) or automated (ultrasonic)?
Debris can be removed from an instrument either by scrubbing the instrument manually with a surfactant or detergent and water or by using automated equipment (e.g. ultrasonic cleaner, washer-disinfector) and chemical agents. After cleaning, instruments should be rinsed with water to remove chemical or detergent residue. Splashing should be minimized during rinsing and cleaning. Considerations in selecting cleaning methods and equipment include their effectiveness, their compatibility with the items to be cleaned, and the occupational health and exposure risks they pose. Because instruments cleaned with automated cleaning equipment do not need to be presoaked or scrubbed, the use of automated equipment can increase productivity, improve cleaning effectiveness, and decrease worker exposure to blood and body fluids. Thus, using automated equipment can be more efficient and safer than manually cleaning contaminated instruments.

B.05 | Should I clean my instruments manually? How do I perform manual cleaning?
We recommend ultrasonic cleaning as the best and most effective way to clean regular instruments, such as hand instruments and forceps, but sharp or delicate or not 100% steel instruments should be cleaned manually. If manual cleaning is not performed immediately, instruments should be placed into a container and soaked with a detergent, a disinfectant/detergent, or an enzymatic cleaner to prevent drying of patient material and make manual cleaning easier and less time consuming. We also recommend using long-handled brushes to keep the hand as far away as possible from sharp instruments.
Steps to follow:

  1. Use stiff plastic cleaning brushes (DB-11, DB-12, nylon tooth brush, etc.) Do not use steel wool or wire brushes except specially recommended stainless steel wire brushes for instruments such as bone files, or on stained areas in knurled handles.
  2. Brush delicate instruments carefully and, if possible, handle them separately from general instruments.
  3. Make sure all instrument surfaces are visibly clean and free from stains and tissue.
  4. After scrubbing, rinse instruments thoroughly under running water. While rinsing, open and close scissors, hemostats, needle holders and other hinged instruments to ensure the hinge areas are fully rinsed, inside and out.

B.06 | How do I perform ultrasonic cleaning?
Using ultrasound combined with a special cleaning solution, it is the most effective cleaning method available. Recommended for regular instruments such as hand instruments and forceps. 
Advantages:
Safer than hand scrubbing.
Cleans instruments very effectively.
Reduces the risk of contaminants spreading through splatter.
Allows for more efficient use of staff time.

Steps to follow:

  1. Sort instruments carefully so as to include only instruments compatible with ultrasonic cleaning
  2. Make certain sharp edges are not touching other instruments
  3. Do not combine different metals (chrome plated, stainless, copper, titanium, etc.).
  4. Change the solution frequently to avoid accumulation of microorganisms.
  5. After rinsing and before sterilization, inspect and dry the instruments thoroughly.

Remember:
 Ultrasonic cleaning is not recommended for instruments which are very delicate, which have sharp cutting edges (scissors, needle holders , bone forceps) and not 100% steel (rubber, mouth mirrors, titanium, TC-tungsten carbide inserts or diamond dusted tips, etc.). The ultrasonic vibrations can chip, break or corrode any welded parts. For the delicate instruments, use manual cleaning.

B.07 | May I use a bleach solution to clean my instruments?
Never use bleach to clean any surgical instruments. The high pH of bleach causes surface deposits of brown stains and might even corrode the instrument. Even high quality stainless steel is not impervious to an acidic bleach solution.

B.08 | What type of personal protective equipment is necessary when cleaning instruments and surfaces?
Instruments should be handled as though contaminated until processed through the sterilization cycle (unless the instrument has been processed with a thermal washer/disinfector that has a high-level disinfection cycle). To avoid injury from sharp instruments, personnel should wear puncture-resistant, heavy-duty utility gloves when handling or manually cleaning contaminated instruments and devices. Because splashing is likely to occur, they should also wear a facemask, eye protection or face shield, and gown or jacket. Employees should not reach into trays or containers holding sharp instruments that cannot be seen. To reduce their risk of injury, they should instead remove instruments using forceps or empty them onto a towel.

B.09 | My scissors are becoming stiff and hard to use, how do I improve their action?
We recommend first cleaning the instruments in a neutral pH detergent solution with distilled water. Then apply a surgical instrument lubricant (commonly referred to as instrument milk).

B.10 | Why sharpen instruments?
Surgical Instruments should be kept identical to their original design. Dental and surgical procedures are most effective when using sharp instruments as they reduce hand and wrist fatigue, improve tactile sensitivity and cutting action, save time, and minimize patient discomfort. Instruments can be sharpened by using different types of stones.

B.11 | How to sharpen surgical instruments?

Steps to follow: 

  1. Place one drop of Sharpen oil (DB-OL) on the stone. Lubrication improves the movement of the instrument blade over the stone; also, it prevents the metal particles from clogging the stone.
  2. Hold the instrument in one hand, while applying the stone to the lateral surface angled with the face of the blade.
  3. Position the stone to contact the heel of the blade and work toward the tip, keeping the stone in contact with the blade throughout the sharpening procedure.
  4. Move the stone up and down with short strokes, placing more pressure on the down stroke. (Do not move the instrument, keep the instrument still).
  5. Finish sharpening the instrument with a down stroke; this will prevent a rough edge from forming.
  6. Evaluate the sharpness with the Teflon testing stick (DB-15). If the blade is still dull, re-evaluate the angle of the stone and repeat the sharpening procedure (steps 2-6)
    Sickle Scaler Toe End: The sickle scaler has a pointed tip and, therefore, the stone is held straight as it nears the tip.

Curette Toe End: The curette has a rounded toe, so the position of the stone is adapted around the rounded cross-section.
With both types of instrument, always finish on a down stroke to remove any flash of metal.

B.12 | Why you should lubricate surgical instruments?
Lubrication is the most important action you can take to extend the life of your instruments. The use of a surgical instrument lubricant (DB-OL) because of the white coloring caused by the emulsion in water will prevent spotting from mineral deposits left behind by water after cleaning. Corrosion can also be prevented by the application of lubricant. Corrosion starts in the pores of the metal and is often related to improper cleaning. With proper handling and lubrication the surface of your stainless steel instruments will develop a thin hard coating, similar to oxidation, which will help prevent damage from corrosion. Known as the passivation layer, it makes the instrument more resistant to staining and rusting. In addition to stain and corrosion protection, lubrication reduces friction at the joints, keeping the action of the instrument light, delicate and smooth and extending the life of the instrument by reducing wear.

B.13 | What is sterilization?
It is a procedure which removes all pathogenic and non-pathogenic micro-organisms; it should be performed with outmost care. These are the most common and effective sterilization techniques: 
• Autoclave (steam sterilization)
• Chemiclave (chemical sterilization)
• Dry heat sterilization (not recommended)
Remember: Ultrasonic cleaning does not sterilize.

B.14 | Do my joint and hinge instruments require any special care during sterilization?
Yes, the application of a lubricant to the hinge is important to insure smooth operation of the hinge. Also, instruments with "locks" must be sterilized in the "open" position. This insures sterility of the instrument and also prevents "heat expansion" against locked instrument jaws that can cause cracking of the jaws (especially on fine needle holders).

B.15 | How do I perform steam sterilization (autoclave)?
Steam autoclave (moist heat) sterilization using a pre-vacuum (forced air removal) cycle is recommended. Instruments are treated with high pressure water steam.
Minimum and maximum recommended standards for Steam Sterilization / Autoclave:
Time: 5-15 minutes
Temperature: 132°C (270°F) - 135°C (275°F)
Sterilizing agent: distilled water.
Advantages:
Highly effective.
Nontoxic.
Inexpensive.
Rapid heating.
Rapid penetration of instruments.

Disadvantages:
Items must be heat and moisture resistant.
Needs good maintenance (The autoclave is not working correctly if steam comes out of the lid or around the door).

B.16 | How do I perform chemical sterilization (chemiclave)?
Instruments are treated with high pressure, with the help of chemical steams. Instruments must be dried before sterilization.
Minimum and maximum recommended standards for Chemical Sterilization / Chemiclave: 
Time: 5-15 minutes
Temperature: 132°C (270°F) - 135°C (275°F)
Sterilizing agent: special chemical solutions..
Advantages:
Minimal dulling, rusting and corroding of instruments.
Unsaturated chemical vapor method is a low-humidity process.
The heat-up time is shorter than for most steam sterilizers.
Easy to operate, fill and purge / Minimal order.

Dis-advantages:
Needs adequate ventilation / It is flammable.
Vapo-Steril solution has formaldehyde in it, known to be a potential carcinogen.
Needs to be mixed with water when disposed.

B.17 | How do I perform dry heat sterilization?
Instruments sterilization takes place by means of hot air. Instruments must be dried before sterilization. At present, this sterilization technique is not recommended, as it does not guarantee reliable sterilization and gradually causes damages.
Minimum and maximum recommended standards for Dry Heat Sterilization: 
Time: 60 - 90 minutes
Temperature: 160ºC (320ºF) - 170º C (340ºF) 

Advantages:
Reaches surfaces of instruments that cannot be disassembled. This is accomplished by conduction.Low cost.

Dis-advantages:
Long exposure time is necessary.
Very high temperatures gradually cause damages such as surface blackening, loss of polish and dullness.Specialized packaging is needed.

B.18 | How do I perform instrument care?
Ensure all instruments are only used for the purpose for which they were designed. Make sure you clean and decontaminate all instruments in warm water immediately after use. Failure to do so may result in the instruments becoming stained and the joints stiff. Instruments should be lubricated after every cleaning process with a water-soluble lubricant and must be thoroughly dried before being stored. Pack instruments carefully with the heavier ones lying on a piece of cloth or towel at the bottom. Store and sterilize bow handled instruments on a special holder. Always leave racks and ratchets open.
Surgical instruments can be re-used, unless indicated otherwise. The life time of instruments depends on the frequency of use, the care of the user and proper reprocessing methods. The most effective method of dealing with instrument problems is to prevent them from occurring. The use of "treated water", careful preliminary cleaning, the use of neutralized PH solution and visual inspection, will help to keep instruments performing accurately free of troublesome stains. It is important to act quickly should a problem arise. 
New Instruments: 
• All new instruments must be processed before use. 
• They must undergo the entire cleaning process. 
• They are usually oiled in production and this must be removed prior to running them through a sterilizer (Do not take from packaging and go to the sterilizer).

B.19 | What factors could affect instrument care?
Water: Regular tap water is not appropriate for instrument sterilization. High chloride and lime concentration and various other minerals can lead to staining or damage of the stainless steel. When water dries, chlorides will concentrate and cause pitting on the instrument. Fully Desalted Water avoids this problem.
Corrosion: Certain compounds are highly corrosive to stainless steel and will cause serious damage despite the passivated protective surface. Instruments should never be exposed to:
Aqua regia ( HNO3+3 HC)
Ferric chloride (FeCl3)
Hydrochloric acid (HCl)
Iodine (I2)
Sulfuric acid (H2SO4)

If instruments are inadvertently exposed to any of these substances, they should be rinsed immediately with copious amounts of water.

B.20 | How to diagnose spots and stains?
It is common for instruments to become stained or spotted despite the best efforts. In nearly all cases these problems are the result of minerals deposited upon the surfaces of the instruments, as well as insufficient cleaning. Proper technique during cleaning and sterilizing procedures will prevent most staining occurrences. The following identifies some of the various instrument-related may encounter:
• Brown/Orange Stains: A result of high-pH detergents. Chlorhexidine usage or improper soaking of instruments. This color stain can also be caused by soaking in tap water.
• Dark Brown Stains: Low-pH instrument solutions. The brownish colored film may also be caused be a malfunctioning sterilizer. Similar localized stain spots can also be a result of baked-on blood.
• Bluish Black Stains: Reverse plating, when instruments of different metal (e.g. chrome and stainless steel) are ultrasonically processed together. This can occur when high quality instruments are mixed with lower end ones. Additionally, exposure to saline, blood, or potassium chloride will cause this bluish black color. (similar to tarnish on silverware).
• Black Stains: Contact with ammonia or a solution containing ammonia.
• Light or Dark Spots: Water droplets drying on the instruments. With slow evaporation, the minerals sodium, calcium and magnesium left behind can cause this spotting.
• Rust Deposits: Dried blood that has become baked on the serrated or hinged areas of surgical instruments. This organic material, once baked on, may appear dark in color. Also can be caused by soaking in tap water.

B.21 | How to remove stains?
Stains can be removed, whereas rust will leave permanent damage. To determine if a brown or orange discoloration is a stain or rust, use the eraser test:
• Rub a pencil eraser over the discoloration.
• It the discoloration is removed with the eraser and the metal underneath is smooth and clean, this is a stain.
• If a pit mark appears under the discoloration, this is corrosion or rust.

B.22 | Does BBC offer sharpening and repair services?
Complete servicing for surgical instruments (such as sharpening, replacement of Tungsten Carbide inserts on needle holders, cleaning and re-polishing, etching, etc.) is available depending on availability in your area.

B.23 | Warnings!
• BBC is not responsible if its products used with improper care / maintenance.
• BBC usually does not define the maximum number of uses appropriate for re-usable surgical instruments. The useful life of these devices depends on many factors including the method and duration of each use, and the handling between uses. Careful inspection and functional test of the device before use is the best method of determining the end of serviceable life for the medical device.
• New instruments must undergo the entire cleaning process before use. Do not take from packaging and go to the sterilizer.
• Avoid putting oxidized or rusty instruments in sterilizing or disinfectant solutions, as other instruments could be attacked.
• Used, damaged and oxidized tools should not be used because they are no longer able to perform their function. Please note that some types of damages (corrosion, rust and spots) are transmitted to the instruments intact.
• Sterilization does not replace the cleaning and maintaining of the instruments.
• Ultrasonic Cleaning does not sterilize.