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ORIGINAL ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 106-110

Sterilization in endodontics: Knowledge, attitude, and practice of dental assistants in training in Nigeria – A cross-sectional study


Department of Restorative Dentistry, University of Benin, Benin, Edo State, Nigeria

Date of Web Publication5-Apr-2018

Correspondence Address:
Dr. Julie Omole Omo
Department of Restorative Dentistry, University of Benin, Benin, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_52_17

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  Abstract 

Objective: To assess the level of knowledge and practice of sterilization of endodontic instruments among future dental surgery assistants undergoing training.
Methodology: Data were collected by means of a self-administered questionnaire consisting of demographics, the knowledge of the respondents with regard to sterilization techniques for endodontic files/reamers and handpieces, the attitude of the respondents to transmission of infection from unsterilized endodontic instruments, the sterilization techniques practiced by the respondents for endodontic instruments and materials, and the source of training/knowledge regarding endodontic sterilization. The data were subjected to statistical analysis in the form of descriptive statistics, frequencies, mean and standard deviation.
Results: Steam autoclave and dry heat sterilizer were the most reported options for sterilization of endodontic files and reamers. About 95.6% of the respondents claim that they often sterilize endodontic instruments in the course of their training. About 83.3% never sterilize gutta-percha while 50.0% claim they always sterilize new files and reamers before initial use. About 82.2% thought infection could always be transmitted from patient to patient if unsterilized files are used for endodontic treatment.
Conclusion: The dental assistants in this study appear to have a fair knowledge of endodontic instrument sterilization; however, they need to expand their scope of practice beyond what is available for use.

Keywords: Dental assistants, endodontics, sterilization


How to cite this article:
Enabulele JE, Omo JO. Sterilization in endodontics: Knowledge, attitude, and practice of dental assistants in training in Nigeria – A cross-sectional study. Saudi Endod J 2018;8:106-10

How to cite this URL:
Enabulele JE, Omo JO. Sterilization in endodontics: Knowledge, attitude, and practice of dental assistants in training in Nigeria – A cross-sectional study. Saudi Endod J [serial online] 2018 [cited 2019 Dec 12];8:106-10. Available from: http://www.saudiendodj.com/text.asp?2018/8/2/106/229353


  Introduction Top


Endodontics is the aspect of dentistry involved in the treatment or precautions taken to maintain the vital pulp, moribund tooth, or nonvital tooth in the dental arch.[1] Reuse of instruments in dentistry is common and endodontic treatment involves the use of instruments which are usually reused. During endodontic instrumentation, vital tissue, dentin shavings, necrotic tissue, bacteria, blood, blood by-products, and other potential irritants are encountered with accumulation of the debris on the flutes of the instruments.[2] Transfer of these debris from patient to patient and to dental staff is highly undesirable, as these debris can act as antigens and infecting agents capable of transmitting diseases such as Creutzfeldt–Jakob disease.[3],[4] The presence of debris has been reported to interfere with sterilization by forming a protective barrier that prevents the complete sterilization of the surface beneath.[5] If this debris is not removed, sterilization procedure may be pointless.[6] In the absence of adequate infection control procedures, there is a high probability of transmitting pathogenic microorganism through endodontic instruments.[5] Sterilization is a process to render an object free from viable microorganisms including bacterial spores and viruses. Sterilization of instruments in dentistry is required to protect patients and oral health care staff from cross contamination through instruments.[7] It is very important for endodontic instruments to be cleaned, disinfected, and sterilized effectively.[3],[4] Various methods for cleaning and sterilizing endodontic instruments have been proposed. These include use of brushes and sponges, ultrasonic cleaning, glutaraldehyde solution, sodium hypochlorite, glass bead sterilization, dry heat, or steam sterilization. The miniature complex architecture of endodontic instruments makes precleaning and sterilization difficult.[5] Hence, devising a sterilization protocol for endodontic instruments have been reported to require careful consideration [7] with suggestions that instruments such as files and burs be considered single-use devices.[8],[9] The need for improvement in disinfection and sterilization in endodontic practice has been highlighted [7] with the need to create awareness among dentists with sterilization in endodontic practice emphasized.[2],[7] Attitude about sterilization of endodontic instruments was reported to be high among dental assistants; however, knowledge and practice were comparatively low.[7] It has been recommended that dental surgery assistants be involved in training programs to raise their awareness regarding the importance of proper sterilization of endodontic instruments along with other instruments.[5] Several studies [2],[3],[5],[7] have assessed the level of knowledge, attitudes, and behavior regarding sterilization in endodontics among dentists. However, there is a paucity of such study among dental surgery assistants who are responsible for cleaning and sterilization of these instruments. This study therefore seeks to assess the level of knowledge and practice of sterilization of endodontic instruments among future dental surgery assistants undergoing training.


  Materials and Methods Top


This was a cross-sectional study of final year dental surgery assistant students undergoing training in Nigeria. Six institutions train dental surgery assistants in Nigeria. Simple random sampling was used to pick the schools for the study. All final year students who gave their consent participated in the study. Data were collected by means of a self-administered questionnaire consisting of 5 sections. The first section consisted of demographic characteristics of the respondents. The second section assessed the knowledge of the respondents with regard to sterilization techniques for endodontic files/reamers and handpieces. The third section appraised the attitude of the respondents to transmission of infection from unsterilized endodontic instruments. The fourth section assessed the sterilization techniques practiced by the respondents for endodontic instruments and materials. The fifth section determined the source of training/knowledge regarding endodontic sterilization. Clarity, feasibility, and quality of the questionnaire were done by pilot survey of 5 practising dental surgery assistants at the University of Benin Teaching Hospital. Data obtained was analyzed using IBM SPSS 21.0 (Chicago, Illinois, USA, 2016). The data were subjected to statistical analysis in the form of descriptive statistics, frequencies, mean and standard deviation.


  Results Top


A total of 90 respondents (30 each) from 3 dental surgery assistants training institutions participated in this study. There was a female preponderance with females accounting for 82.2% (74) and males 17.8% (16) giving a male: female ratio of 1:4.6. The respondents' age ranged from 18 to 35 years with a mean age of 22.46 ± 3.1 years with majority (92.2%) of the respondents belonging to the 18–26 years age group.

Assessment of knowledge regarding sterilization techniques for endodontic files and reamers revealed that the most reported options for sterilization among the respondents were steam autoclave (58.9%) and dry heat sterilizer (54.4%) while only 10.0% of the respondents knew that glass bead sterilization could be used to sterilize files and reamers. Less than half (43.3%) reported the possibility of using chemical sterilization technique for files and reamers. A few (6.7%) of the respondents reported that ultrasonic cleaner is one of the techniques for sterilization of endodontic files and reamers. Less than a quarter (15.6%) of the respondents reported that chemical autoclave was an option for sterilization of endodontic files [Table 1]. [Table 2] depicts the knowledge of the various sterilization techniques for handpieces used during endodontic treatment. Very few (7.8%) claimed glass bead sterilization was an option for sterilization of handpieces. Chemical sterilization was reported as an option among 52.2%, steam autoclave among 26.7%, ultrasonic cleaner among 11.1%, dry heat sterilizer among 43.3%, and chemical autoclave among 12.2% of the respondents. With regard to the respondents' perception about transmission of infection through unsterilized files, 82.2% thought infection could always be transmitted from patient to patient if unsterilized files are used for endodontic treatment. Less than half (47.8%) thought infection could always be transmitted from patient to dentist while 54.4% thought infection could always be transmitted from patient to dental surgery assistant if unsterilized files are used for endodontic treatment [Table 3].
Table 1: Options for sterilization of endodontic files and reamers among the respondents

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Table 2: Options for sterilization of handpieces used for endodontic treatment among the respondents

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Table 3: Perception regarding transmission of infection from unsterilized endodontic files and reamers

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Most (95.6%) of the respondents claimed they often sterilize endodontic instruments in the course of their training with 85.6% always sterilizing files, reamers, and burs. Majority (83.3%) never sterilized gutta-percha while 50.0% claimed they always sterilize new files and reamers before initial use. Less than a quarter (24.4%) of the respondents thought it possible to sterilize files between two teeth of the same patient while 56.7% thought surface disinfection while using files is possible. Majority (92.2%) claim they always remove debris from files and reamers before sterilization with 90.0% of the respondents reporting soaking the files and reamers in sodium hypochlorite solution before brushing while 18.9% reported soaking in hydrogen peroxide before brushing. Majority (97.8%) claimed they use ultrasonic cleaning alone before sterilization. Cleaning of the metal shaft of files and reamers was reported to be done always by 88.9% of the respondents while 90.0% claimed they always clean the plastic handles of files.

Majority (97.8%) of the respondents claimed that in the course of their training, they sterilized burs after endodontic treatment. [Table 4] shows that 70.5% have used autoclave to sterilize burs, 59.8% have used hot air oven while 4.6% reported glass bead sterilization. Majority opined they had received training on sterilization of endodontic instruments with classroom lectures being the source for 61.9% and clinical attachment/posting for 85.7% of the respondents. Other sources of training/knowledge reported by the respondents were internet 25.0%, seminars 14.3%, and textbooks 32.1%.
Table 4: Practice of sterilization of burs used during endodontic treatment among the respondents

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  Discussion Top


Dental surgery assisting is still a female-dominated profession in Nigeria as depicted in previous studies [10],[11],[12] and supported by findings in this study. Sterility is not graded; it is either an instrument is sterile or it is not.[13] The respondents of this study were of the opinion that infection could be transmitted through unsterilized files from patient to patient. This depicts good knowledge regarding diseases transmission during endodontic procedures as the goal of sterilization of instruments in dentistry is to prevent cross contamination between patients.[13] Especially as it has been shown that diseases may be transmitted by indirect contact if dental instruments used on a patient that have become contaminated are reused for another patient without adequate sterilization between uses.[14] Hence, most dental jurisdiction mandates that all endodontic instruments be sterilized before reuse.[15]

The main methods of sterilization of endodontic files and reamers have been reported to be application of steam under pressure in a steam autoclave,[14],[16],[17],[18] application of dry heat in a sterilizing oven, and sterilization by chemical vapor.[14],[16],[18] The findings of this study show that dental assistants in training are aware of steam autoclave and dry heat oven sterilization techniques for sterilization of endodontic instruments but not the use of chemical autoclave. This may be due to what is practiced at their training centers as majority of them were exposed to the use of steam autoclave and dry heat oven for sterilization of endodontic instruments as well as the effectiveness of these methods as the use of steam autoclave to sterilize endodontic instruments has been reported to show total sterility.[16],[17],[18]

Other techniques for sterilization of endodontic files and burs reported in the literature include glass bead sterilization,[16],[17],[18] glutaraldehyde and carbon-dioxide lasers,[16] ethylene oxide gas, and hot salt sterilization.[17] Salt sterilization and glutaraldehyde solution have been shown to be inadequate, and they should not be relied upon to completely sterilize instruments.[17]

Glass bead sterilizers are a fast chairside sterilization technique for endodontic instruments as they can easily be placed in the operatory; hence, files, reamers, and burs can be sterilized immediately before, during, and after procedures but precleaning is recommended.[19],[20] However, findings of this study show that glass bead sterilization is not a popular means of sterilization among the respondents in this study as only 7.8% were aware of its use for sterilization compared to 32% reported among dentists.[5] This may be because glass bead sterilizers and salt sterilization were used to transfer dry heat to endodontic canal instruments. These sterilizers are no longer approved for use because of the possibility that clinicians relied on them for sterilization between patients. One study also found that they were ineffective at killing spores on cotton and paper products.[21]

The possibility of sterilizing files during endodontic treatment of the same patient was observed among a few respondents. However, it has been shown that endodontic instruments used for recapitulation in a canal as it is progressively decontaminated may be disinfected chemically.[22]

There is increased advocacy for burs and files to be single-use devices as routine sterilization procedures have been observed not to be effective,[23],[24] and 100% sterility between patients cannot be guaranteed.[25] At present, there is no universal standard for preparation and sterilization of endodontic instrument before reuse.[5] However, an experiment carried out to illustrate the financial cost of file reuse showed that the pecuniary cost of reusing files seems to be interesting as it was an illusion as the cost-saving simply does not justify a risk that cannot be accurately evaluated.[25]

It has been shown that new burs and files as packaged by manufacturers are not sterile.[23] This may be why about half of the respondents always sterilize new files and reamers before initial use which is higher than that reported among dentists.[2],[5]

Manual cleaning of endodontic instruments to remove remnants by means of small soft wire brushes is recommended practice and this can be achieved by thermo disinfection (cleaning/disinfection in a disinfectant), mechanical chemical cleaning, and manual chemical cleaning.[20] Majority of the respondents claim they always remove debris from files and reamers before sterilization by soaking the files and reamers in sodium hypochlorite solution before brushing. Ultrasonic cleaning before sterilization was observed to be popular among the respondents in this study. This may be because ultrasonic cleaning has been shown to be an effective and time-saving method of cleaning instruments although it is not capable of removing all contamination.[13],[20]

Dental handpieces tend to have features and designs that make them difficult to clean/sterilize. Although autoclavable handpieces are available, the main method for decontaminating handpieces has continued to be disinfection of the external surfaces rather than sterilization with a previous study reporting use of cloth impregnated with disinfectant.[26] Various sterilization techniques for handpieces used during endodontic treatment were reported by the respondents, this may be because there is no validated cleaning process for handpieces.[26] It has been reported that metal shafts of files and reamers are cleaned while the plastic handles are forgotten.[5] This was not the case in this study as majority of the respondents claim to clean the metal shaft of files and reamers as well as the plastic handles always.

Burs tend to be unique due to their complex architecture which makes precleaning and subsequent sterilization difficult.[18] In the course of endodontic treatment, dental burs may become contaminated with necrotic tissues, blood, saliva, and pathogens. In this study, autoclave seems to be a more popular technique for sterilizing burs than hot air oven. Although council on dental materials, instruments, and equipment recommend dry heat oven as the preferred method of sterilization of dental burs due to the reduced rusting and dulling of instruments.[17] However, the most commonly used methods of sterilization of burs include soaking of burs in commercially available disinfectants followed by manual cleaning, use of ultrasonic baths, or autoclaving.[27]

It has been asserted that dental assistants are not trained for sterilization protocols, and there is need to raise the sensibility of dental assistants regarding the importance of sterilizing endodontic instruments.[5] However, the respondents in this study claim to have received training on sterilization of endodontic instruments with clinical attachment/posting being the major source of training.


  Conclusion Top


The dental assistants in this study appear to have a fair knowledge of endodontic instrument sterilization; however, they need to expand their scope of practice beyond what is available for use.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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2.
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Izu KH, Thomas SJ, Zhang P, Izu AE, Michalek S. Effectiveness of sodium hypochlorite in preventing inoculation of periapical tissues with contaminated patency files. J Endod 2004;30:92-4.  Back to cited text no. 22
    
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Morrison A, Conrod S. Dental burs and endodontic files: Are routine sterilization procedures effective? J Can Dent Assoc 2009;75:39.  Back to cited text no. 23
    
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Sureshchandra B, Meeta M, Rajaram N. Endodontic files: Are routine sterilization procedures effective? Endodontology 2001;23;47-50.  Back to cited text no. 24
    
25.
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26.
Smith A, Smith G, Creanor S, Hurrell O, Bagg J, Lappin D. Handpiece decontamination survey. Vita 2009;6:321-2.  Back to cited text no. 26
    
27.
Sheriteh Z, Hassan T, Sherriff M, Cobourne M. Decontamination procedures for tungsten carbide debonding burs: A cross-sectional survey of hospital-based orthodontic departments. J Orthod 2010;37:174-80.  Back to cited text no. 27
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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