| Abstract|| |
Aim of this Study: The aim was to evaluate the efficiency of different sterilization methods on extracted human teeth (EHT) by a systematic review of in vitro randomized controlled trials.
Methodology : An extensive electronic database literature search concerning the sterilization of EHT was conducted. The search terms used were “human teeth, sterilization, disinfection, randomized controlled trials, and infection control.” Randomized controlled trials which aim at comparing the efficiency of different methods of sterilization of EHT were all included in this systematic review.
Results : Out of 1618 articles obtained, eight articles were selected for this systematic review. The sterilization methods reviewed were autoclaving, 10% formalin, 5.25% sodium hypochlorite, 3% hydrogen peroxide, 2% glutaraldehyde, 0.1% thymol, and boiling to 100°C. Data were extracted from the selected individual studies and their findings were summarized.
Conclusion: Autoclaving and 10% formalin can be considered as 100% efficient and reliable methods. While the use of 5.25% sodium hypochlorite, 3% hydrogen peroxide, 2% glutaraldehyde, 0.1% thymol, and boiling to 100°C was inefficient and unreliable methods of sterilization of EHT.
Keywords: Autoclaving; extracted human teeth; formalin; sterilization methods; systematic review
|How to cite this article:|
Western J S, Dicksit DD. A systematic review of randomized controlled trials on sterilization methods of extracted human teeth. J Conserv Dent 2016;19:343-6
|How to cite this URL:|
Western J S, Dicksit DD. A systematic review of randomized controlled trials on sterilization methods of extracted human teeth. J Conserv Dent [serial online] 2016 [cited 2021 Jun 21];19:343-6. Available from: https://www.jcd.org.in/text.asp?2016/19/4/343/186457
| Introduction|| |
Extracted human teeth (EHT) are routinely used by students for performing preclinical exercises, for preparing ground sections, and for research. Since they harbor bloodborne pathogens and are a potential source of infection, they must be sterilized before use. The efficiency of several sterilization methods is comparatively evaluated in a number of randomized controlled trials. There exists a need to systematically summarize the current knowledge regarding this issue.
The objective of this study was to systematically organize all the studies evaluating the efficiency of different sterilization methods of human teeth and to determine efficient methods by summarizing the findings from individual studies.
| Methodology|| |
This systematic review was conducted following the preferred reporting items for systematic reviews and meta-analyses guidelines to ensure optimum quality., An extensive literature search concerning the sterilization of EHT was conducted in electronic databases of PubMed, LILACS, Scopus, Google Scholar, and hand searching reference lists from relevant journals. The keywords used were “Human Teeth, Sterilization, Disinfection, Randomized Controlled Trials, and Infection Control.” The search resulted in a total of 1618 articles. After removal of irrelevant articles and duplicates, the abstracts of the selected 43 articles were screened. Studies evaluating the effect of different sterilization methods on the physical and chemical composition of tooth structure were all eliminated. For the remaining twenty articles, full text was retrieved and they were screened based on the following predetermined study eligibility criteria.
Studies that were (1) done from 1990 to 2015, (2) in English, (3) randomized controlled trials, (4) done in EHT, (5)in vitro studies, (6) comparing the efficacy of at least one method of sterilization of EHT with that of a control group.
studies that were (1)in vivo studies, letters, comments, editorials, questionnaire surveys, case reports, proceedings, personal communications, and any type of literature reviews, (2) done in nonhuman teeth, (3) with no control group, (4) with outcome measures not defined clearly.
A flowchart diagram of the study selection process is given in [Figure 1]. List of studies with references and their reasons for exclusion as numbered in the study exclusion criteria is given in [Table 1].
|Table 1: List of studies and their reasons for exclusion as numbered in the exclusion criteria|
Click here to view
| Results|| |
[Table 2] summarizes the method of data collection, synthesis, and extraction from the eight selected primary studies. In this systematic review, percentile efficiency of each sterilization method is calculated from the total number of samples tested and the total number of samples which had no microbial growth after being subjected to the particular sterilization method.
|Table 2: The method of data synthesis and data extraction from the selected primary studies|
Click here to view
Autoclaving method and usage of 10% formalin showed 100% efficient sterilization. The other methods of sterilization (5.25% sodium hypochlorite, 3% hydrogen peroxide, 2% glutaraldehyde, 0.1% thymol, and boiling to 100°C) all showed inefficient sterilization, percentile efficiency of which are also presented in [Table 2].
| Discussion|| |
Extracted teeth are prone to colonization by potentially pathogenic bacteria and need to be sterilized properly  before use in teaching laboratory and research. Scientific literature has documented various randomized controlled trials comparing various methods of sterilization of EHT. Although several narrative literature reviews ,, were done in the past, there are no systematic reviews done in this field. The objective of this systematic review was to identify all randomized controlled trials evaluating the efficiency of different sterilization methods of EHT, to determine the total number of trials done to date, to assess the quality of those trials, to determine whether a particular sterilization method works better than the others based on the findings from the primary individual studies, and to identify gaps in knowledge where new trials are still needed.
The present systematic review concluded that autoclaving and 10% formalin are very efficient and reliable methods of sterilization of EHT; 5.25% sodium hypochlorite, 3% hydrogen peroxide, 2% glutaraldehyde, 0.1% thymol, and boiling to 100°C are all inefficient and unreliable methods of sterilization of EHT.
While the data obtained from this review are valuable, its application to practice may be limited because these methods of sterilization reviewed have their own set of advantages and disadvantages. Autoclaving and 10% formalin do not alter the feel and cutting characteristics; therefore, they do not compromise the learning experience when used for preclinical exercises. Autoclaving causes disruption of collagen  and denature the organic component in dentin, which can alter the hybrid layer after resin penetration. Therefore, autoclaving makes the teeth not suitable for use inin vitro studies testing the microhardness, bond strength, and microleakage. The tooth containing dental amalgam restorations should not be autoclaved because the vaporized mercury  can be inhaled subjecting the patients and dental personnel to health risk. Formalin causes stabilization of the collagen preventing their collapse, which allows increased mechanical interlocking of the restorative material to the dentin. This makes it unsuitable for use inin vitro microleakage and bond strength research., Formalin is a skin and eyes irritant, cytotoxic, genotoxic, and carcinogenic. Therefore, although being an efficient sterilization method, its use is discontinued as it poses a major health hazard.
Limitations of this systematic review are (1) preferable inclusion of articles in English, (2) restricted time frame from 1990 to 2015, (3) other methods of sterilization including gamma radiations, chemiclave, dry heat, microwave, benzalkonium chloride, 0.5% chloramine, 2% sodium azide, iodophor, phenol, alcohol, and antibiotics could not be included because of lack of sufficient number of studies carried out using these methods for effective comparison, (4) perceived weakness of such disinfection efficiency evaluation studies may be due to inherent variations in the microbial composition, microbial load, and biofilm matrix composition  between individual tooth used in different studies, (5) it is not coupled with a meta-analysis because there is a mix of comparisons of different sterilization methods with diverse outcomes in the primary studies, (6) although the concentration of disinfectant solutions used were all standardized while summarizing this systematic review, the time limit of each sterilization method used in the primary studies could not be standardized.
Excluding gamma radiations, all the other sterilization methods tested so far resulted in changes in properties of tooth structure. Therefore, there exists a need to find out a feasible and efficient sterilization method suitable for use in teeth to be used forin vitro studies. Further, this review brings into light the need for new ideas and methods for sterilization of root canal space of extracted teeth to be used in preclinical endodontics.
| Conclusion|| |
This systematic review concluded that autoclaving and 10% formalin were 100% efficient and reliable methods of sterilization of EHT; autoclaving method may be the definitive method for sterilizing teeth used for preclinical conservative exercises. Usage of 10% formalin, although effective, is discouraged due to associated health risks. 5.25% sodium hypochlorite, 3% hydrogen peroxide, 2% glutaraldehyde, 0.1% thymol, and boiling to 100°C are all inefficient and unreliable methods of sterilization of EHT. This systematic review also brings into light the need for sterilization methods and protocol needed for sterilization of extracted teeth to be used for preclinical endodontics and inin vitro studies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sandhu SV, Tiwari R, Bhullar RK, Bansal H, Bhandari R, Kakkar T, et al.
Sterilization of extracted human teeth: A comparative analysis. J Oral Biol Craniofac Res 2012;2:170-5.
Tate WH, White RR. Disinfection of human teeth for educational purposes. J Dent Educ 1991;55:583-5.
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. Open Med 2009;3:e123-30.
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al.
Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1.
Amith HV, D'cruz AM. Attitude and practice on handling of extracted teeth for educational use among the students of a dental college in Southern India. Int J Med Dent 2014;4:147-53.
Hashemipour MA, Mozafarinia R, Mirzadeh A, Aramon M, Nassab SA. Knowledge, attitudes, and performance of dental students in relation to sterilization/disinfection methods of extracted human teeth. Dent Res J (Isfahan) 2013;10:482-8.
Smitha D, Tijare MS, Amith HV, Gujjar KR, Sharma R. Knowledge, attitude and practice regarding handling of extracted human teeth among students of a dental college in Bhopal. J Indian Assoc Public Health Dent 2014;12:276-82.
Albrecht L, Ferreira EL, Passos ML, Cecchetti RT. Teeth processing in human teeth bank – Proposal of protocol. RSBO 2013;10:386-93.
Viana PS, Machado AL, Giampaolo ET, Pavarina AC, Vergani CE. Disinfection of bovine enamel by microwave irradiation: Effect on the surface microhardness and demineralization/remineralization processes. Caries Res 2010;44:349-57.
Cuny E, Carpenter WM. Extracted teeth: Decontamination, disposal and use. J Calif Dent Assoc 1997;25:801-4.
White RR, Hays GL. Failure of ethylene oxide to sterilize extracted human teeth. Dent Mater 1995;11:231-3.
Abdul-Rahman Gh Y, Al-Ashou WMO, Shukur AM. Disinfection of extracted teeth for dental researches. Al-Rafidain Dent J 2010;10:158-61.
Tabrizizadeh M, Abrisham M, Dehghan Marvasti F. Comparison of different techniques for disinfection of teeth internal space in preclinical teaching. J Dent Med 2009;22:120-4.
White JM, Goodis HE, Marshall SJ, Marshall GW. Sterilization of teeth by gamma radiation. J Dent Res 1994;73:1560-7.
Pantera EA Jr., Schuster GS. Sterilization of extracted human teeth. J Dent Educ 1990;54:283-5.
Tijare M, Smitha D, Kasetty S, Kallianpur S, Gupta S, Amith H. Vinegar as a disinfectant of extracted human teeth for dental educational use. J Oral Maxillofac Pathol 2014;18:14-8.
Chandki R, Maru R, Gunwal M, Garg A, Mishra A. A comparison of different methods for disinfection or sterilization of extracted human teeth to be used for dental education purposes. World J Dent 2013;4:29-31.
Hope CK, Griffiths DA, Prior DM. Finding an alternative to formalin for sterilization of extracted teeth for teaching purposes. J Dent Educ 2013;77:68-71.
Ghosh A, Chowdhury S. Sterilization and disinfection of extracted human teeth for institutional use. Int J Clin Dent Sci 2013;4:9-12.
Nikita VL, Vidya BS, Sham SB. Disinfection methods of extracted human teeth. J Oral Health Community Dent 2007;1:27-9.
Kumar M, Sequeira PS, Peter S, Bhat GK. Sterilisation of extracted human teeth for educational use. Indian J Med Microbiol 2005;23:256-8.
Dominici JT, Eleazer PD, Clark SJ, Staat RH, Scheetz JP. Disinfection/sterilization of extracted teeth for dental student use. J Dent Educ 2001;65:1278-80.
Beatriz HS, Marili DA, Vania PD, Rosimeire TR, Edvaldo AR. Contaminant microbiota associated to extracted human teeth. Rev Clin Pesqui Odontol 2004;1:19-21.
DeWald JP. The use of extracted teeth forin vitro
bonding studies: A review of infection control considerations. Dent Mater 1997;13:74-81.
Attam K, Talwar S, Yadav S, Miglani S. Comparative analysis of the effect of autoclaving and 10% formalin storage on extracted teeth: A microleakage evaluation. J Conserv Dent 2009;12:26-30.
Salem-Milani A, Zand V, Asghari-Jafarabadi M, Zakeri-Milani P, Banifatemeh A. The effect of protocol for disinfection of extracted teeth recommended by center for disease control (CDC) on microhardness of enamel and dentin. J Clin Exp Dent 2015;7:e552-6.
Centers for Disease Control and Prevention (CDC). Guidelines for infection control in dental health-care settings-2003. MMWR Recomm Rep 2003;52:1-61.
Neghab M, Soltanzadeh A, Choobineh A. Respiratory morbidity induced by occupational inhalation exposure to formaldehyde. Ind Health 2011;49:89-94.
Cogliano V, Grosse Y, Baan R, Straif K, Secretan B, El Ghissassi F, et al.
Advice on formaldehyde and glycol ethers. Lancet Oncol 2004;5:528.
Dr. J Sylvia Western
600, Main Road, Western Electricals, Tisaiyanvillai, Tirunelveli, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]