Infection control in orthodontic office
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Content
Infection Principles of infection transmission Principles of infection control Infection control in orthodontic office Sterilization & disinfection Studies on infection control in orthodontic office www.indiandentalacademy.com
Infection
“Multiplication & survival of microorganisms on
or in the body”
Cross infection
“The passage of microorganisms from one person to other”.
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History of sterilization
Leeuwenhoek(17 century)
Simple microscope
Described microbes(shape-cocci,bacilli,spiral)
Father of bacteriology
Edward Jenner(1749-1823)
Modern method of vaccination-small pox
Originally vaccination-injection cowpox-prevent smallpox
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Tyndall First-sterilization method Fractional sterilization
Pasteur(1822-1895) Father of microbiology Introduced-techniques of sterilization Steam sterilizer,hot air oven,autoclave Pasteurization www.indiandentalacademy.com
Joseph listure(1827-1912)
Father of antiseptic surgery
Disease-invading organisms-germ theory of disease
Diluted phenol-wound infection
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Robert koch(late19-early20)
Staining bacterial smears
Pure culture technique
Koch's postulate
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Infection control
“Governing or limiting of the spread of infections via different channels, in a specific or general environment”.
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Goals
risk of cross contamination
To correct break in aseptic technique
To use universal precautions
To protect pt’s & personnel- Infection
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Principles of Infection Transmission 1.
A Source Infection
2.
A Mode / Vehicle
3.
Root of transmission
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Source of Infection 1. With Overt Infection
Droplets, Discharges from mouth / Portals
2. Prodromal Stage of Infection
Viral Infection – Measles, Mumps, Chicken Pox
3.Carriers Convalescent / Asymptomatic Hepatitis B www.indiandentalacademy.com
Universal Infection Control Patient Carrier ?????
Reservoir of Pathogens
Universal Precaution www.indiandentalacademy.com
Dentist
Patient Microorganism Blood
Respiratory
Oral www.indiandentalacademy.com
HIV
HBV
HSV-1,2
CMV
TB-bacilli
Streptococci & Staphylococci www.indiandentalacademy.com
Route of Transmission Direct Contact
Indirect Contact
•Blood
•Contaminated instruments
•Oral fluids
•Operatory Equipments
•Other Secretions
•Aerosols
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Aerosols
Influenza, Common cold, TB
High speed Instruments > 100 µ Spatter
< 100 µ - Common
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Chain of Infection Susceptible Host
Virulent Pathogen
Portal of Entry
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Index Case
Other Patients
Dentist
Infection Control www.indiandentalacademy.com
Infection Control Protocol 1.
Pt Evaluation
2.
Personal Protection
3.
Sterilization & Disinfection
4.
Safe Disposal of Waste
5.
Lab Asepsis www.indiandentalacademy.com
Pt Evaluation ď Ž
Medical History
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Personal Protection 1.
Personal Hygiene
2.
Clinic Clothing
3.
Barrier Protection
4.
Immunization Procedures www.indiandentalacademy.com
Personal Hygiene
Scrubbing
Touching
Cover – Cuts & Bruises
Washing – Hands
Finger nails www.indiandentalacademy.com
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2.Clinic Clothing •Uniform •Daily change •Washing •OSHA-clinic premises www.indiandentalacademy.com
Barrier Protection 1.
Gloves
2.
Eye Shields
3.
Face mask
4.
Rubber dam isolations www.indiandentalacademy.com
Gloves
Disposable – new pair
Latex / Vinyl
Change – Long Procedures
After removal – washing hands
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Eye Shields
Dentists – Support Personnel
Spatter – Debris
High speed Instrumentation
OSHA-fitted-solid side shields
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Face Mask
High speed instrumentation
Aerosol – inhalation RTI
Life – 30 to 60 minutes
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Vaccines for Dentists
CDC & OSHA
Recommendation
Vaccines • HBV, •Influenza, •rubella www.indiandentalacademy.com
•Measles
Sterilization & disinfection
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Sterilization “The process by which an article surface or medium is freed of all microorganisms either in vegetative or in spore state”.
Disinfection “Destruction of all pathogenic organisms capable of giving rise to infection”. www.indiandentalacademy.com
Antisepsis “Indicate the prevention of infection ,usually by inhibiting the growth of bacteria”.
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Physical agents 1.
Sunlight
2.
Drying
3.
Dry heat
4.
Moist heat
5.
Filtration
6.
Radiation
7.
Ultrasonic & sonic vibrations www.indiandentalacademy.com
Chemical agents 1.
Alcohols
2.
Aldehydes
3.
Dyes
4.
Halogens
5.
Phenols
6.
Surface active agents
7.
Metallic salts
8.
Gases
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1.Sunlight
Bactericidal & germicidal
U.V rays & heat rays
2.Drying
Moisture- bacterial growth
Spores- unaffected www.indiandentalacademy.com
3.Heat
Most reliable
Factors
1)
Nature of heat-
2)
Temperature & time
3)
Number of microorganisms
4)
Characteristics of organisms
5)
Type of material from which the organisms - eradicated www.indiandentalacademy.com
1.Nature of heat Dry Heat
Moist Heat
• Coagulation of Proteins •
Electrolytes
•Denaturation & Coagulation of Proteins
• Oxidative damage www.indiandentalacademy.com
2.Time & Temperature
Time α
1 Temperature
Thermal Death Time
“Minimum time required to kill a suspension of organisms at a predetermined temp in a specific environment” www.indiandentalacademy.com
3. No of Micro-organisms
Sterilization time
α No of Microorganisms
4.Characteristics of Microorganisms Sterilization time
Spore
α Strain www.indiandentalacademy.com
5.Type of Material - Host Organic Content
Spore
Difficult to Eradicate www.indiandentalacademy.com
Heat Dry Heat
Moist Heat
1.Flaming
1.Pasteurization
2.Incineration
2.Boiling
3.Hot air oven
3.Steam 4.Autoclave
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Flaming
Bunsen flame – Red hot Forceps point Spatulas Scalpel Needles
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Incineration Burning Solid dressings Bedding Pathological material
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Hot air oven
Widely used – 160ºC / 1 hr
Electricity
Even distribution of air
Dry
Forceps
Scissors
Scalpels
Syringes
Swabs www.indiandentalacademy.com
Moist Heat
Pasteurization (< 100ºC) 63 ºC / 30 min
Non-sporing MO
TB-Bacilli
Brucella
Salmonella
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Boiling (100ºC)
x
Disinfection
Surgical Instruments
Steam (> 100ºC)
Steam
Condenses to Water
Microbicidal Activity
Liberate Latent Heatwww.indiandentalacademy.com
Steam at atmospheric pressure
Free steam-culture media
90 mins
Sugar containing medias 100ºC / 20 mins
3 successive days Tyndalisation
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Steam Sterilizers
Types
Lab Autoclaves
Hospital dressing sterilizer
Bowl & Instrument sterilizer
Rapid cooling sterilizer
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Autoclave
Principle > 100ºC Under pressure Pressure - Inside Closed chamber
Temperature
Saturated Steam Penetrating power
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Materials
Instruments
Dressings
Lab ware Types of Autoclaves
High vaccum
Downward displacement
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High vaccum
Vaccum suction
Downward displacement
Steam enters top of chamber
Air â&#x20AC;&#x201C; Evacuated
Downward displacement of air
EX- Central Sterile supply units in hospitals
EX- Automatic Bench top Autoclave www.indiandentalacademy.com
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Sterilization Cycle 1.
Heating Period
2.
Holding Period
3.
Cooling Period
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Sterilization Efficacy (Monitoring) ď Ž
Spores of Bacillus Stearo-thermophilus
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Time-Temp Temperature
Holding Time (Min)
120ยบC
15
126ยบC
10
134ยบC
3
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Filtration
Heat labile substances
Antibiotic solutions
Sera
Carbohydrate solution
Types-Candle filters -Asbestos filters -Sintered glass filters -Membrane filters www.indiandentalacademy.com
Radiation
Ionization
X-rays, γ-rays, cosmic rays Highly lethal to DNA
Non-ionizaion
EMR wavelength > visible light
Ex- IR, UV.
Hospital wards, OT www.indiandentalacademy.com
Ultrasonic's & Sonic rays
High frequency of sound waves beyond the range of human ear.
Variable sensitivity towards Micro-organisms
Commonly used in dentistry. www.indiandentalacademy.com
Chemical Sterilization
Chemical agents – Requirements
1.
Wide spectrum
2.
Active – Organic matter
3.
Speedy Action
4.
High penetrating power
5.
Stable
6.
Non-corrosive www.indiandentalacademy.com
Mode of action
Protein coagulation
Disruption of cell-membrane
Removal of Sulfates groups
Substrate competition (Competitive Inhibition) www.indiandentalacademy.com
Types of Chemical agents
Alcohols
Aldehydes
Dyes
Halogens
Phenols
Surface actives agents
Gases
Metallic salts www.indiandentalacademy.com
Alcohols
Ethyl alcohol & Isopropyl alcohol
Skin Antiseptics 60-70% Denaturation of Proteins No action on spores
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Sterilium
Bacteria,antibiotic resistant bacteria,tubercle bacilli,fungi,viruses
Composition 2 propanol-4.5gm 1propanal-30gm ethyl-hexadecyl-dimethyl www.indiandentalacademy.com
Aldehydes Formaldehyde Against Amino group in Protein Bactericidal &
Sporicidal Preserve anatomical specimen's 10 % formalin
Gluteraldehyde Similar to Formaldehyde Effective against TB-bacilli, fungi & Virus www.indiandentalacademy.com
Korsolex
Total bactericidal,fungicidal,tuberculocidal,sporicidal,
viricidal(HBV,HIV,polio etc)
Mainly contains gluteraldehyde-7gm/100gm,rust inhibitor
www.indiandentalacademy.com Ortho-pliers, cutters,arch wires
Chemical sterilization for Orthodontic appliances
Bands Plastic boxes – Dipping gluteraldehyde
Least critical Instruments Soaking in 2% Gluteraldehyde (100 mins)
8% Formaldehyde in Alcohol 2% Aqueous soln of Activated Gluteraldehyde
Removable
Immerse Iodophors / Chlorine www.indiandentalacademy.com
Dyes
Anilines
Acridine
Bacteriostatic (High dilution)
Bactericidal (Low dilution)
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Halogens
Iodine (Aqueous / Alcoholic soln.)
Skin disinfectant
Bactericidal & Moderately Sporicidal
Chlorine
Water supply
Swimming pools
Food industry
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Phenols
Coal tars – Lister
Cell membrane damage
Microbicidal
Hospitals
Ex – Chlorheixidine G +VE www.indiandentalacademy.com
Gases
Ethylene oxide
Colorless – highly penetrating gas – all type of MO
Heart , lung machines, respirators, dental equipments
Explosive
Formaldehyde
Fumigation of OT
β- propiolactone
More effective for fumigation
Low penetrating power www.indiandentalacademy.com
Surface active agents
Wetting agents, Detergents & Emulsifiers 1.
Anionic (Soap)
2.
Cationic
3.
Nonionic
4.
Amphoteric
Commonly used Cationic – Cell membrane Alkaline pH www.indiandentalacademy.com
Metallic Salts
Action α CONC
Salts of Heavy mestals – greater action
Salts of Hg, Cu, Ag Disinfectants
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Stages of sterilzation
Pre-sterilzation cleaning
Packing
The sterilization process
Aseptic storage www.indiandentalacademy.com
Pre-sterlization cleaning
Remove-contaminated instruments
Heavy duty household gloves,eye shields&face masks-cleaning.
Sharps-carefull
Needles- capped. www.indiandentalacademy.com
In dentistry Methods Manual scrubbing Ultrasonic cleaning.
Cleaning efficiency
Aerolization
Sharp injuries www.indiandentalacademy.com
Packing
Open tray system-sealed - bags
Perforated trays-fitted covers
Individual packing-bags
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Sterilization process (Dentistry)
Moist heat(autoclave)
Dry heats
Gaseous chemicals(chemiclave)
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Glass bead Sterilizer 218-246ºC for 3-5 seconds Glass beads 1.2 – 1.5 mm Hottest pasrt
Peripherally
Larger the instruments
Longer the
time www.indiandentalacademy.com
Chemiclave
Formaldehyde+alchohol+acetone+ketone+steam -138kpa-127ºC
Dual-toxic chemicals – heat – 30 mins
Faster
Non corrosive. www.indiandentalacademy.com
Sterilization cycle Residual moisture Long term effect on instruments Cycle interuption
Autoclave
Chemiclave
Hot-air oven
Short (3-30 mins) Present
Intermediate (30-45 mins) Present
Long (> 60 mins)
Corrosion / Rust
Minimal Corrosion / rust
Temper / Brittleness of Sharp edges
Not possible
Not possible
Possible
Chemical hazards
Spontaneous combustiion of vapor >125ยบC
Other hazards Nil
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Nil
Monitering Sterilization
Process / Chemical Indicators
Liquid / Paper
Assure the efficacy of Sterilization cycle
Biological Indicators
Prove the Sterilization
Bacteriospores – Placed – most difficult areas
Weekly based www.indiandentalacademy.com
Storage of Sterilized Instruments
Sterilized instruments Stored in a sterile state
Closed protected area of clinic with minimal air flow – Cabin / Drawer
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Office Disinfection/ Lab asepsis
Wipe – 70% Isopropyl alcohol
Chair
Table
Light handles
Spittoon
3 way - Syringe www.indiandentalacademy.com
Hand piece Straight tubing Non-retraction valve Minimize the no of tubing & wires Flush with running water-20-30sec Sterilization-autoclave,dry heat,chemical www.indiandentalacademy.com
Impression disinfection
Immerse –
0.5 – 1% Sodium hypochlorite ( 60 mins)
4% Formaldehyde (10 mins)
Gluteraldehyde
Spraying
0.5% Chlorhexidine in 70% Alcohol
UV – Disinfection unit
Antiseptic alginate impression material www.indiandentalacademy.com
Disposal of Waste
Sharp instruments & Needles, tissues / blood Disposed with special Precaution
Disposable Needles, scalpels / other sharp items Placed into Puncture resistant container
Clinical
+
Domestic waste www.indiandentalacademy.com
Classifcation of Dental instruments 1.
Critcal Instruments -Surgical / Penetrating mucosa -Scalpels, Burs, Scalars, chisels -Bands, Band-removers, Ligature directors, band forming pliers
1.
Semi-Critical -Instruments touching mucosa -Mirrors, Retractors
3.
Non-critical -Ligature tire, Distal end cutters, tying pliers www.indiandentalacademy.com
ADA-Reccomendations for Infection control in Dental office â&#x20AC;&#x201C;JADA 1996
Instruments
Autoclave
Hot air oven Chemiclave
Burs
_
++
++
Handpieces
++
_
+
Impression trays
++
+
++
Mirrors
_
++
++
Saliva ejectors
_
_
_
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Orthodontic pliers -High quality SS
++ -Low quality SS _ -With Plastic parts _ _
++ ++ __
++ ++ __
Water air syringe tips
++
++
++
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Studies on Infection control in orthodontic office www.indiandentalacademy.com
Sterilization & Disinfection in Orthodontic office â&#x20AC;&#x201C; a practical approach -Payne GS , AJO 1986
Rinsing in Running water Draining
Ultrasonic cleaner â&#x20AC;&#x201C; 5 mins
www.indiandentalacademy.com Running water
Dried
Alcoholic solution â&#x20AC;&#x201C; remove residual water
Dry Chemiclave - 20 mins
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Glass bead Sterilization of Orthodontic bands -Smith GE, AJO 1986
Purpose of Study 1.
Determining bead sterilization – Ortho bands
2.
Minimal time – bands inoculated – bacteria & spores
3.
Compare bead sterilization with other methods for sterilizing orthodontic bands www.indiandentalacademy.com
10 bands – bacillus subtilis spores / staph albus
10 controls- Inoculated –nt in sterilizer
Bands placed 1 at a time
226ºC -15, 30, 45, 60 secs
BHI broth - 37ºC / 3 days
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Results :-
15 secs – Bacterias
45 secs – Spores
5 bands – simultaneously – twice the time
Other techniques
5 sec tap water rinse
10 sec soap scrub
30 min – alcohol flame www.indiandentalacademy.com
Ineffective in killing Bacteria & spores
Sterilization of Orthodontic Instruments & Bands in Cassetes Hohit WF et al 1990 AJO ď Ž
OMS-ASAPsys Cassette Contaminated instruments ď&#x192; Dried
Placed in cassettes
Ultrasonically cleaned
Rinsed & Dried
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Steam, Chemical vapor, Dry heat
Instruments Cultured
Results 1. Residual spores – Ultrasonic's – Killed 2. 3 Types of Sterilization Equally effective
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Effect of clinical use &sterilization on selected orthodontic arch wires Smith GA et al 1992, AJO
Study method
3 types of nitinol,1type of β-titanium,1-stainless steal wires-clinically treated
20 wires
5 wires-control(unused)
Autoclave,cold sterilization,disinfection,dry heat www.indiandentalacademy.com
Subjected-load deflection,tension,corrosion tests
Results
No clinical significance-property-new&used
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Comparison of 3 dry heat covection sterilizers 1. 2. 3.
Cox Sterilizer Dentronix –DDS Feberware
Carcao G JCO 1993: 27 ; 259
1. Spores All the 3 units 100% 2. Tested for Hardness Surface discoloration Dulling Hinge looseness
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Effects of 3 types of Sterilization on Orthodontic pliers - Mazzocchi AR, JCO 1994
Design Testing Distal end cutters & Ligature cutters – 500 cycles of Autoclave, Chemiclave and dry heat sterilization
Each instrument was checked for
Hardness
Surface discoloration
Tarnish
Before & After Sterilization
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Results
All cutters -
Hardness – Greatest (Autoclaved ) -Least (Dry heat)
Surface discoloration
- All Pliers
Worst discoloration Chemiclave instruments
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Infection control in orthodontic office in CANADA -Mccarthy GM et al , AJO 1997 ď Ž ď Ž
Comaprison of Infection control methods Between General Dentists and Orthodontics
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Orthodontists
General Dentists
Gloves
85%
92%
Masks
38%
75%
Protective eye wear
60%
84%
Changing gloves after each patient Heat sterilization of hand piece Hep B vaccination
84%
96%
57%
84%
94%
92%
Addn Precaution HIV
80%
78%
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Blood & Hepatitis B Contamination through aerosols during debonding -(Toroglu MS et al, Angle Orthodontist 2003, vol 73, 571) Study design:-26 Patients (16 yrs) -Aerosol samples collected â&#x20AC;&#x201C; Saliva ejectors -Serum, excess fluid and aerosol samples of 3 hepatitis B carrier is tested -ELISA / PCR www.indiandentalacademy.com
Results
Blood – All aerosols & Excess flluids
Hbs Ag – 2 Hepatitis B Carriers
HBV – DNA 1 excess fluid sample
Both 1 hepatitis B carrier
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HIV – HBV Special Precaution
Routes of transmission – Dentistry Blood Aerosols Rotary instruments Saliva
Evidence ???????? www.indiandentalacademy.com
Precaution 1. In relation to Blood – Body fluids
Barrier methods
2. In relation to Injection & Skin Piercing
Needle – Extra care -Disposed in Puncture proof container
3. Effective use of Sterilization & Disinfection Autoclave Dry heat Chemiclave Gluteraldehyde
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References
Essential microbiology for dentistry-L.P samaranayake
Text book of microbiology-Ananthanarayan&paniker
Medical microbiology- Satish gupte
Principles of endodontics- Grossmen
Comparison of 3 dry heat convection sterilizers-George carcao,JCO-1993 www.indiandentalacademy.com
Bead sterilization of orthodontic bands-Jerald E smith, AJO1996
Effect of 3 types of sterilization on orthodontic pliers-Mazzocchi etall, JCO1994
Possibility of blood & hepatitis contamination through aerosoles generated during debonding procedures-Toroglu et all, AJO2003
Sterilization &disinfection in orthodontic office: A practical approach-Payne s, AJO1986 www.indiandentalacademy.com
Infection control in orthodontic office in canada-Mc carthy et all AJO1997
Effect of clinical use & sterilization on selected orthodontic arch wires-Glenn et all AJO1992
Infection control recommondations for the dental office & dental laboratory-Assosiation report JADA 1996
HIV disease in India-Hand book for dental proffesionls- D.C.I publication
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www.indiandentalacademy.com Leader in continuing dental education
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